Biomedical subjects
Publications and source records attributed to G French.
We found that a high proportion of reusable tourniquets are contaminated with blood and bacterial pathogens. Their use contravenes hospital cross-infection control protocols and we therefore recommend the use of disposable tourniquets.
Gemifloxacin is a new quinolone and, like moxifloxacin, trovafloxacin, grepafloxacin and clinafloxacin, is more potent in vitro than ciprofloxacin or ofloxacin against Gram-positive aerobes. Gemifloxacin was the most potent of the quinolones tested against streptococci and most ciprofloxacin-resistant pneumococci were susceptible to gemifloxacin. Gemifloxacin, like moxifloxacin, trovafloxacin, grepafloxacin and clinafloxacin, was more potent than ciprofloxacin or ofloxacin against all staphylococci and many ciprofloxacin-resistant isolates were susceptible to these quinolones. Against Gram-negative aerobes gemifloxacin was as potent as or slightly less potent than ciprofloxacin, and isolates resistant to ciprofloxacin were also resistant to gemifloxacin and to moxifloxacin, trovafloxacin and grepafloxacin. Gemifloxacin was also the most potent quinolone against Gram-positive anaerobes and fusobacteria but trovafloxacin was the most potent agent tested against other Gram-negative anaerobes.
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Enterococci have become important nosocomial pathogens, with Enterococcus faecalis and then Enterococcus faecium predominating. Because of the emergence of glycopeptide (vancomycin and teicoplanin) resistance in enterococci, laboratories have been required to screen for resistant strains and to identify them to the species level. This has resulted in the need for accurate identification of species less commonly associated with clinical infections, such as Enterococcus casseliflavus and Enterococcus gallinarum, which are inherently resistant to the glycopeptides. Studies evaluating commonly used commercial identification systems, have found error rates for enterococcal species identification of 2-21% for E. faecalis, 5-9% for E. faecium, and 14-79% for other species. Reporting errors may have adverse effects on the management of clinical infections, as well as in the control of multidrug-resistant strain outbreaks. The purpose of this document is to present a simplified approach to the identification of Enterococcus species that uses a combination of rapid, readily available, and inexpensive tests.
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Titin is a giant protein that spans half of the striated muscle sarcomere. The I-band portion of titin extends as the sarcomere is stretched, developing what is known as passive force. This portion of the molecule is composed mainly of tandem immunoglobulin (Ig) segments, consisting of serially linked Ig-like domains, and a recently discovered unique sequence termed the PEVK segment. The tandem Ig and PEVK segments have been suggested to extend sequentially when sarcomeres are stretched, with PEVK extension dominating at moderate to high degrees of sarcomere stretch (M. Gautel and D. Goulding, 1996, FEBS Lett. 385, 11-14; W. Linke et al., 1996, J. Mol. Biol. 261, 62-71; K. Trombitás et al., 1998). Previously we observed that the anti-titin antibody 9D10 labels a region in the I-band that increases in width as sarcomeres are stretched. Here we tested whether 9D10 labels the PEVK segment. The 9D10-labeled region of human soleus fibers was followed by immunoelectron microscopy as sarcomeres were stretched. It was found that 9D10 labeled a region in the I-band that was approximately 100 nm wide at a sarcomere length of 2.4 micrometer and approximately 550 nm wide at a sarcomere length of 4.0 micrometer. Results were compared with those obtained with sequence-specific antibodies that were used to mark the boundaries of the PEVK segment. Findings indicate that 9D10 labels the PEVK segment from close to its N-terminal end to its C-terminal end. Consistent with this conclusion are the results on cardiac myocytes that express a much shorter PEVK segment than skeletal muscle and where 9D10 labels a region that is much less wide than in skeletal muscle. The anti-titin antibody 9D10 is a useful tool for investigating the extensible behavior of the PEVK segment in both skeletal and cardiac muscles.
Between July and September 1997 a ceftazidime- and aminoglycoside-resistant strain of Klebsiella pneumoniae infected or colonized seven patients on three paediatric wards at Guy's Hospital in London. The patients were mostly neonates or infants recovering from cardiac surgery for congenital defects. The organism was probably introduced by an asymptomatic patient from Greece and the subsequent outbreak could largely be explained by person-to-person spread on individual wards and frequent transfers of patients between wards. The outbreak was controlled by patient isolation and attention to handwashing, and there were no fatalities. The organisms were non-typeable by serology but had a characteristic RAPD profile. They produced the extended spectrum beta-lactamase SHV-5 and the aminoglycoside-modifying enzymes AAC(6') + probably AAC(3)II, encoded on a conjugative plasmid of approximately 160 kb. Two other patients had multi-resistant klebsiellas, one of them an SHV-5 producer and one a TEM-5 producer, but these could be distinguished from each other and from the outbreak strain by serological and RAPD typing and by the genetics and mechanisms of their resistances. Three other multi-resistant enterobacteria were isolated during the outbreak: an Escherichia coli that had acquired the 160 kb resistance plasmid from the epidemic klebsiella, a Citrobacter isolated from one of the patients with the klebsiella but which did not produce SHV-5, and a TEM-5-producing Enterobacter. This outbreak illustrates the importance of screening patients from high-risk areas for multiply-resistant organisms on admission, and the value of bacterial typing and analysis of resistance mechanisms to define the epidemiology of hospital infection.
Treatment failures with vancomycin prompted us to investigate the phenomenon of tolerance to glycopeptides in recent clinical isolates of Staphylococcus aureus. We used both MBC/MIC determinations and time-kill measurements to study tolerance to vancomycin and teicoplanin in 35 blood or heart valve isolates of S. aureus from patients with endocarditis or bacteraemia. There was generally good agreement between vancomycin tolerance indicated by an MBC:MIC ratio of > or =32 and by < or =90% kill after 6 h incubation in the presence of 20 mg/L vancomycin. However, two isolates were tolerant according to their MBC:MIC ratios but non-tolerant as judged by time-kill measurements. Seven of 15 methicillin-resistant S. aureus (MRSA) isolates but only two of 20 methicillin-susceptible ones were tolerant as judged by time-kill experiments (chi2 = 4.27 with Yates' correction, P = 0.04). Seven of the 16 isolates from patients with endocarditis were tolerant, compared with only two of the 19 isolates from patients with other conditions (chi2 = 3.43 with Yates' correction, P = 0.06). Within the endocarditis and non-endocarditis subgroups, tolerance was associated more frequently with methicillin resistance than with susceptibility, but the numbers were too small for the differences to be statistically significant. Most of the vancomycin-tolerant isolates were also tolerant to teicoplanin. We conclude that glycopeptide tolerance is a real phenomenon in S. aureus, particularly amongst MRSA isolates, and can be reliably determined by our method of time-kill analysis. Tolerance may compromise glycopeptide therapy of serious S. aureus infection and should be taken into account when deciding treatment.
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Representative isolates from 10 distinct extended-spectrum beta-lactamase-producing strains of Klebsiella pneumoniae that caused hospital outbreaks in the United Kingdom from 1991 to 1994 were examined for relationships between their enzymes and plasmids. The beta-lactamases were identified by a combination of isoelectric focusing and gene sequencing. SHV-2 beta-lactamase was produced by isolates from four outbreaks, SHV-5 was involved in three, and SHV-4, TEM-15, and TEM-26 were involved in one outbreak each. All of the extended-spectrum beta-lactamases were encoded by self-transmissible plasmids, with sizes ranging from about 70 to 160 kb. No similarities between the restriction digest patterns of the extended-spectrum beta-lactamase-encoding plasmids were detected, except to some extent between those that produced TEM-15 and TEM-26. Thus, outbreaks of hospital infection with these organisms in the United Kingdom from 1991 to 1994 involved distinct organisms and resistance plasmids and appeared to be unrelated.
We report a survey of beta-lactamases and their transferability in Klebsiella spp. isolated from blood during 1992-95. beta-Lactamases were characterized by determination of isoelectric point (pI), by hybridization of plasmid DNA preparations with probes for SHV and TEM sequences and by PCR with SHV- or TEM-specific primers. There were 80 isolates of Klebsiella pneumoniae and 22 isolates of Klebsiella oxytoca. Most isolates of K. pneumoniae had a chromosomally encoded SHV-1 beta-lactamase (or a closely related enzyme); K. oxytoca also produced chromosomal beta-lactamases, but these were distinct from SHV-1. Plasmid-encoded beta-lactamases were rare in Klebsiella spp., being found in six (7.5%) isolates of K. pneumoniae and in none of the K. oxytoca. beta-Lactamase activities were relatively low (< 100 nmoles nitrocefin hydrolysed per minute per mg of protein) and ampicillin MICs were < or = 128 mg/L for most isolates of both species. However, all isolates of K. pneumoniae with plasmid-encoded beta-lactamases, three other isolates of K. pneumoniae and three isolates of K. oxytoca had high beta-lactamase activities (> 100 nmoles/mg/min) and very high ampicillin MICs (> or = 1024 mg/L).
Some isolates of SHV-5 beta-lactamase-producing Klebsiella pneumoniae K2 from a single-strain outbreak of cross-infection produced approximately five-fold more beta-lactamase than others. We investigated three possible genetic mechanisms of this hyperproduction: the presence of a more powerful promoter, an increase in plasmid copy number or an amplification of the gene on a plasmid. No differences between low and high beta-lactamase producers were detected in the promoter region of the SHV-5 beta-lactamase gene, which closely resembled that of SHV-2. SHV-5 beta-lactamase production was encoded on a low copy number plasmid, but DNA-DNA hybridization with an SHV-specific probe detected a higher gene dose in hyperproducers. The beta-lactamase hyperproduction was unstable on repeated subculture, with a reduction of about 75% after 100 generations. Hyperproducing mutants of a low-producing Klebsiella and its Escherichia coli K-12 transconjugants could be selected in vitro at a frequency of 10(-5) to 10(-6) and these variants had an increased SHV-5 beta-lactamase gene copy number on low copy number plasmids. We conclude that hyperproduction of the extended-spectrum beta-lactamase was caused by gene amplification that could be easily lost or gained in vitro. Since the change to hyperproduction occurred at a high frequency and hyperproducers showed increased resistance to many beta-lactams and beta-lactam/beta-lactamase inhibitor combinations, we suspect that these variants may readily be selected in patients during antibiotic therapy.
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Among Escherichia coli organisms isolated at St. Thomas's Hospital during the years 1990 to 1994, the frequency of resistance to amoxicillin-clavulanic acid (tested by disk diffusion in a ratio of 2:1) remained constant at about 5% of patient isolates (10 to 15% of the 41 to 45% that were amoxicillin resistant). Mechanisms of increased resistance were determined for 72 consecutively collected such amoxicillin-clavulanic acid-resistant isolates. MICs of the combination were 16-8 micrograms/ml for 51 (71%) of these and > or = 32-16 micrograms/ml for the remainder. The predominant mechanism was hyperproduction of enzymes isoelectrically cofocusing with TEM-1 (beta-lactamase activities, > 200 nmol of nitrocefin hydrolyzed per min per mg of protein) which was found in 44 isolates (61%); two isolates produced smaller amounts (approximately 150 nmol/min/mg) of such enzymes, and two isolates hyperproduced enzymes cofocusing with TEM-2. Eleven isolates produced enzymes cofocusing with OXA-1 beta-lactamase, which has previously been associated with resistance to amoxicillin-clavulanic acid. Ten isolates produced increased amounts of chromosomal beta-lactamase, and four of these additionally produced TEM-1 or TEM-2. Three isolates produced inhibitor-resistant TEM-group enzymes. In one of the enzymes (pI, 5.4), the amino acid sequence change was Met-67-->Val, and thus the enzyme is identical to TEM-34. Another (pI, 5.4) had the substitution Met-67-->Ile and is identical to IRT-I67, which we propose now be given the designation TEM-40. The third (pI, 5.2) had the substitution Arg-241-->Thr; this enzyme has not been reported previously and should be called TEM-41. The rarity and diversity of inhibitor-resistant TEM-group enzymes suggest that they are the result of spontaneous mutations that have not yet spread.
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LG-Medical (LGM) vena cava filters were inserted percutaneously in 64 patients. Each case was followed after the filter insertion. Clinical follow-up was available in all patients; in 11 patients it was the only form of follow-up. Findings were available from autopsies in seven patients, plain abdominal radiographs in 42, and duplex sonograms of the insertion vein and inferior vena cava (IVC) in 46. A filter was inserted without major complication in all patients. The filter failed to open fully in four patients and was tilted in the IVC in 15. Recurrent pulmonary embolism was found in two patients (fatal in one), and inconsequential filter migration occurred in 11. Introduction vein thrombosis occurred in four patients. IVC thrombosis, demonstrated at autopsy or sonography, was found in 14 patients (22%) and was symptomatic in six (9%). This report suggests that the LGM filter is easy to introduce, and few complications are associated with insertion. The rate of caval thrombosis, however, may be higher than previously reported.