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Moving from recommendation to implementation and audit: part 1. Current recommendations and programs: a critical commentary.

Growing concern over the spread of resistance to antibiotics and other antimicrobials has prompted a plethora of recommendations for its control. Strategic programs for resistance containment have been initiated in various countries, particularly in Western Europe and North America. The World Health Organization and the European Union have responded to the need for international action by publishing guidance and encouraging collaboration. These recommendations rightly focus on controlling resistance in the community. They agree on the importance of surveillance of resistance patterns and antibiotic usage and the need to encourage judicious antibiotic usage (especially through education of prescribers and the public). Yet there remains a pressing need for the implementation of effective actions to address these issues. Important considerations given less attention include infection prevention (e.g. through immunization), the use of rapid diagnostic tests to reduce antibiotic usage, audit of implemented actions, and the provision of feedback. Furthermore, research is necessary to fill the substantial gaps in our knowledge. Notably, the reversibility or containment of resistance with the optimization of antibiotic usage has yet to be definitely established. For now, antimicrobial management programs should focus on ensuring the most appropriate use of antimicrobials rather than simply on limiting choices. Finally, developed countries must recognize that a truly global approach to resistance containment will require greater support for developing countries.

Anti-Bacterial Agents↗

Expression of resistance to tetracyclines in strains of methicillin-resistant Staphylococcus aureus.

A diverse collection of methicillin-resistant Staphylococcus aureus (MRSA) isolates resistant to tetracycline was screened by PCR for the presence of the resistance determinants tetK, tetL, tetM or tetO. Twenty-four of 66 isolates had tetM alone, 21 had tetK alone and 21 had both tetK and tetM (tetKM). All isolates were tetL- and tetO-negative. MICs of tetracycline, doxycycline and minocycline were evaluated for all isolates with or without preincubation in the presence of subinhibitory concentrations of tetracycline or minocycline. All isolates with one or more tetracycline resistance determinants were resistant to tetracycline 8 mg/L without induction of resistance. Some MRSA isolates of each of these three genotypes showed an unexpected lack of resistance to tetracyclines when the disc diffusion or agar dilution method was applied to uninduced cells. Resistance to tetracycline and doxycycline was greater (two- to four-fold) in tetK cells preincubated with tetracycline (tetK MRSA isolates were susceptible to minocycline </=0.25 mg/L under all conditions tested). For isolates with tetM alone, preincubation with tetracycline or minocycline gave up to a four-fold increase in the level of resistance to doxycycline and minocycline. Induction of doxycycline and minocycline resistance was clearly observed for tetKM isolates when cells were preincubated with minocycline. This study suggests that, despite the results of susceptibility testing, all tetracycline-resistant S. aureus isolates should be treated as resistant to doxycycline, and all tetM-positive isolates should be treated as resistant to all tetracyclines. A double disc diffusion method has been developed to identify inducible resistance to minocycline and to distinguish between tetK, tetM and tetKM isolates.

Genes, Bacterial↗

Two new E colicins, E8 and E9, produced by a strain of Escherichia coli.

We have isolated a strain of Escherichia coli from chicken caeca which produces two E colicins and colicin M. This strain has seven plasmids, five of which have been transferred to E. coli K12. Two E. coli K12 derivatives which produce the two E colicins separately have been tested against seven standard E colicin producing strains which define seven different immunity groups. Our results indicate that these new E colicins define two further immunity groups, E8 and E9.

Animals↗

Role of the microbiology laboratory in infectious disease surveillance, alert and response.

Surveillance is usually defined as the ongoing and systematic collection, analysis and interpretation of health data essential to the planning, implementation and evaluation of public health practice. During recent years, most of these programmes have been developed in the field of antimicrobial resistance and nosocomial infections, but efforts have also been made in other areas. Recent experiences of emerging microbial threats, including severe acute respiratory syndrome and new influenza variants affecting humans, the re-emergence of infectious disease problems and the possibility of bioterrorism have evidenced the need for implementation of infectious disease surveillance programmes. clinical microbiology laboratories play a pivotal role in these programmes. They have the first opportunity to detect these problems and should participate in the design of reporting strategies and dissemination of this information. Policies for the flow of data to national and international authorities should be established using passive surveillance strategies. However, active surveillance programmes taking advantage of new methodologies, including virtual tools and mathematical programs, should be the goal for early detection of unusual patterns of microbial pathogens, outbreaks and healthcare-associated infections. In addition, early implementation of response strategies should be designed and performed with the cooperation of microbiology laboratories, and intervention and response protocols should be defined with the participation of clinical microbiologists.

Communicable Disease Control↗

An approach to management of critical indoor air problems in school buildings.

This study was conducted in a school center that had been the focus of intense public concern over 2 years because of suspected mold and health problems. Because several attempts to find solutions to the problem within the community were not satisfactory, outside specialists were needed for support in solving the problem. The study group consisted of experts in civil engineering, indoor mycology, and epidemiology. The studies were conducted in close cooperation with the city administration. Structures at risk were opened, moisture and temperature were measured, and the causes of damage were analyzed. Microbial samples were taken from the air, surfaces, and materials. Health questionnaires were sent to the schoolchildren and personnel. Information on the measurements and their results was released regularly to school employees, students and their parents, and to the media. Repairs were designed on the basis of this information. Moisture damage was caused mainly by difficult moisture conditions at the building site, poor ventilation, and water leaks. Fungal genera (concentrations <200 colony-forming units (cfu)/m(3), <3000 cfu/cm(2)) typical to buildings with mold problems (e.g., Aspergillus versicolor, Eurotium) were collected from the indoor air and surfaces of the school buildings. Where moisture-prone structures were identified and visible signs of damage or elevated moisture content were recorded, the numbers of microbes also were high; thus microbial results from material samples supported the conclusions made in the structural studies. Several irritative and recurrent symptoms were common among the upper secondary and high school students. The prevalence of asthma was high (13%) among the upper secondary school students. During the last 4 years, the incidence of asthma was 3-fold that of the previous 4-year period.

Adolescent↗

Physiological study of cooperative infection by restricted bacteriophage T1.

The ability of certain phages to successfully infect a restricting host at a high multiplicity of infection is known as cooperative infection or cooperation. We have examined the ability of unmodified T1 (T1.0) to participate in cooperative infection in cells possessing the P1 restriction system. We have found that cooperation is dependent upon protein synthesis during the first few minutes after phage infection. However, we have been unable to attribute the necessary protein to a known T1 cistron. Degradation of the restricted T1 genome is approximately equally extensive whether cooperative infection occurs or whether it is blocked by chloramphenicol. It is postulated that an inducible host repair mechanism may be responsible for the phenomenon of cooperative infection.

Chloramphenicol↗

[Therapy of tuberculosis].

The accomplishment of the principles for the prevention of a germ resistance and the development of new principles of treatment and highly effective antituberculotics has led to the fact that nowadays actually each case of tuberculosis may be treated and cured purely internally. This progress in the individual treatment were achieved by recommendations of therapy which are actualized from time to time. The modern treatment consists of a daily application of three effective antituberculotics for two to three months, fellowed by an intermittent application twice a week. The duration of the initial intensive period and the whole time of therapy is determined by the clinical and social state before the beginning and by the combination of drugs. INH, rifampizine, streptomycin and ethambutol form the components of the therapy combinations which at present are to be used no longer than twelve months. The redetection of the special microbiological qualities of the pyrazineamide and their importance for the prevention of relapses introduces the last phase of the development of the therapy of tuberculosis. By its means it is possible to shorten the duration of the treatment to 9 months and less and thus to increase the acceptability and cooperation, to decrease the toxicity and costs.

Alanine Transaminase↗

Biodegradability of imidazolium and pyridinium ionic liquids by an activated sludge microbial community.

Ionic liquids (ILs) are novel organic salts that have enormous potential for industrial use as green replacements for harmful volatile organic solvents. Varying the cationic components can alter the chemical and physical properties of ILs, including solubility, to suit a variety of industrial processes. However, to complement designer engineering, it is crucial to proactively characterize the biological impacts of new chemicals, in order to fully define them as environmentally friendly. Before introduction of ILs into the environment, we performed an analysis of the biodegradability of six ILs by activated sludge microorganisms collected from the South Bend, Indiana wastewater treatment plant. We examined biodegradability of 1-butyl, 1-hexyl and 1-octyl derivatives of 3-methyl-imidazolium and 3-methyl-pyridinium bromide compounds using the standard Organisation for Economic Cooperation and Development dissolved organic carbon Die-Away Test, changes in total dissolved nitrogen concentrations, and 1H-nuclear magnetic resonance analysis of initial and final chemical structures. Further, we examined microbial community profiles throughout the incubation period using denaturing gradient gel electrophoresis (DNA-PCR-DGGE). Our results suggest that hexyl and octyl substituted pyridinium-based ILs can be fully mineralized, but that imidazolium-based ILs are only partially mineralized. Butyl substituted ILs with either cation, were not biodegradable. Biodegradation rates also increase with longer alkyl chain length, which may be related to enhanced selection of a microbial community. Finally, DGGE analysis suggests that certain microorganisms are enriched by ILs used as a carbon source. Based on these results, we suggest that further IL design and synthesis include pyridinium cations and longer alkyl substitutions for rapid biodegradability.

Electrophoresis↗

The potential for clinical guidelines to impact appropriate antimicrobial agent use.

Practice guidelines can help clinicians and microbiologists improve the quality and efficiency of health care. Numerous areas are in need of guideline development and development of quality improvement programs. These areas include antibiotic control, duration of antibiotic administration, use of narrowest spectrum, least toxic, lowest cost-effective antibiotic, use of rapid diagnostic tests, management of outpatient intravenous antibiotics, antibiotic prophylaxis for surgery, switching from intravenous to oral antibiotics, antibiotic selection for special situations, diagnosis of Lyme disease, and several other topics. IDSA, SHEA, CDC, NIH, and other organizations are cooperating to develop these guidelines.

Anti-Bacterial Agents↗

Oral absorption of cephalosporin antibiotics. 1. Synthesis, biological properties, and oral bioavailability of 7-(arylacetamido)-3-chloro cephalosporins in animals.

A number of 7-(arylacetamido)-3-substituted cephalosporins were prepared and tested in animals for oral absorbability. Bioavailability in mice, rats, dogs, and monkeys was determined after oral or parenteral administration. Oral bioavailability of five compounds selected for more intensive study was generally higher than that of penicillin V in all species tested. The results of ED50 testing against experimental infections in mice generally supported the bioavailability studies. Antibiotic activities were evaluated against Gram-positive and Gram-negative organisms with some derivatives expressing in vitro activity similar to cefaclor. The plasma half-life in rats was relatively short and the plasma curves were strongly influenced by probenecid, indicating rapid renal secretion. Some 7-(arylacetamido)-3-chloro cephalosporins are orally absorbed in animals to a greater extent than penicillin V, and antibacterial agent of proven clinical utility.

Administration, Oral↗

Susceptibility of multiresistant strains of Burkholderia cepacia to honey.

Twenty strains of Burkholderia cepacia, isolated principally from the sputum of cystic fibrosis patients, were tested for their susceptibility to eight antibiotics with a modified Kirby-Bauer Disc diffusion technique. All strains exhibited multiple but not identical patterns of antibiotic resistance. The sensitivity of all strains to honey was assessed with an agar dilution method. All strains exhibited susceptibility to concentrations of honey below 6% (v/v). This suggests that honey may have a potential role in the clinical management of B. cepacia infections.

Burkholderia Infections↗

Breakpoints of gross deletions coincide with non-B DNA conformations.

Genomic rearrangements are a frequent source of instability, but the mechanisms involved are poorly understood. A 2.5-kbp poly(purine.pyrimidine) sequence from the human PKD1 gene, known to form non-B DNA structures, induced long deletions and other instabilities in plasmids that were mediated by mismatch repair and, in some cases, transcription. The breakpoints occurred at predicted non-B DNA structures. Distance measurements also indicated a significant proximity of alternating purine-pyrimidine and oligo(purine.pyrimidine) tracts to breakpoint junctions in 222 gross deletions and translocations, respectively, involved in human diseases. In 11 deletions analyzed, breakpoints were explicable by non-B DNA structure formation. We conclude that alternative DNA conformations trigger genomic rearrangements through recombination-repair activities.

Base Composition↗

Achromobacter species (CDC group Vd): morphological and biochemical characterization.

Twenty-three isolates of Achromobacter species (CDC group Vd) were examined morphologically and biochemically. Gram stains revealed gram-variable bacilli frequently curved or hooked at one pole and often coryneform in shape and arrangement. Electron microscopy revealed the presence of extracellular material in polar accumulations and demonstrated the polar flagella arrangement seen by light microscopy to be lateral. Two colony types were produced; one was minute and watery at 24 h (35 degrees C) progressing to large, mucoid colonies at 48 h, and the other type was shiny, glistening, opaque but nonmucoid. All isolates grew on MacConkey agar and produced catalase, oxidase, and urease. Most grew on salmonella-shigella agar, reduced nitrate to nitrite and gas, hydrolyzed esculin, deaminated phenylalanine (2 to 4 days) and produced H2S in triple sugar iron agar (4 to 12 days). Oxidation of carbohydrates was weak, delayed, and limited to glucose and xylose. Two isolates also oxidized maltose, mannitol, and sucrose. The ability of miniaturized "nonfermenter" kits to identify Achromobacter species was tested. The Minitek (Baltimore Biological Laboratory, Cockeysville, Md.) and N/F (Corning, Roslyn, N.Y.) systems, respectively, identified 21 and 19 of the 23 isolates, whereas the Oxi/Ferm (Roche, Nutley, N.J.) identified 13 and the API 20E (Analytab Products, Plainview, N.Y.) identified only 3.

Alcaligenes↗

Chemical modification of some gentamicins and sisomicin at the 3''-position.

Chemical and photochemical oxidative methods of de-N-methylation of some gentamicins and sisomicins at the 3''-position are described. Selective acetylation of gentamicins and sisomicins at the 1, 3, 2' and 6' and of gentamicin B at the 1, 3, and 6'positions are achieved by treatment of the free bases with carbon dioxide prior to acetylation. De-N-methylation of the above selectively blocked gentamicins and sisomicins followed by re-alkylation at the 3''-position and de-N-protection gives a series of 3''-N-alkyl analogues. The in vitro antibacterial properties of the new derivatives of gentamicins and sisomicins are given.

Acetylation↗