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Ototoxicity caused by aminoglycosides is ameliorated by melatonin without interfering with the antibiotic capacity of the drugs.

The production of free radicals seems to be involved in the mechanisms of ototoxicity. Aminoglycosides produce ototoxicity, which can be determined through distortion product otoacoustic emissions (OAEs) that measure the activity of the outer hair cells of the organ of Corti. An ototoxic chart was obtained in rats using gentamicin or tobramycin. Together with this treatment, the animals ingested melatonin in the drinking water, or melatonin was injected subcutaneously or intramuscularly. The distortion product OAEs were determined over a prolonged period of time for each of the groups. The effect of melatonin on the antibiotic capacity of the aminoglycosides used was also studied. Antibiograms inoculated with Escherichia coli or Pseudomonas aeruginosa and treated with gentamicin or tobramycin in the presence or absence of melatonin at quantities from pharmacological to physiological doses were performed. The ototoxicity produced by gentamicin and tobramycin was maximal from days 3 to 5 post-treatment, returning to normal values in 2 wk. When melatonin was present, the recovery was at day 5 post-treatment, independently of the means of administration of the pineal product. The antibiograms showed that melatonin had no effect on the antibiotic capacity. It is concluded that the ototoxicity caused by gentamicin and tobramycin is ameliorated by melatonin and that the pineal hormone does not interfere with the antibiotic capacity of these antibiotics.

Animals↗

Is hospital-acquired intravascular catheter-related sepsis associated with outbreak strains of coagulase-negative staphylococci?

Macrorestriction fragment profile analysis by pulsed field gel electrophoresis was used to type strains of coagulase-negative staphylococci (CNS) isolated from 30 patients with catheter-related sepsis at the University Hospital Birmingham NHS Trust, UK. Twenty-three infections were hospital-acquired. A total of 56 CNS were isolated from the patients and identified by API as Staphylococcus epidermidis (54), Staphylococcus lugdunensis (1) and Staphylococcus hominis (1). The micro-organisms were further characterized by antibiograms and restriction digestion using SmaI. Analysis of the macrorestriction fragment profiles demonstrated that the isolates from 24 patients were distinct, whereas a common genotype of S. epidermidis was isolated from the blood cultures of six patients, all of whom had acquired this infection in hospital. Three of these patients were located in a haematology ward, two on an intensive care unit and one on a dialysis unit. The data from this current study suggests that specific strains of S. epidermidis may be an important cause of nosocomial catheter-related sepsis resulting from cross-infection, and that this association would not be detected by conventional typing methods including biotyping and antibiograms.

Catheterization, Central Venous↗

Molecular investigation of two clusters of hospital-acquired bacteraemia caused by multi-resistant Klebsiella pneumoniae using pulsed-field gel electrophoresis and in frequent restriction site PCR. Infection Control Group.

Two molecular typing methods, DNA macrorestriction analysis with XbaI resolved by pulsed-field gel electrophoresis (PFGE) and infrequent restriction site PCR (IRS-PCR) assay with adapters designed for XbaI and HhaI restriction sites, were used to investigate two clusters of hospital-acquired bacteraemia associated with multi-resistant Klebsiella pneumoniae which occurred in a paediatric intensive care unit (PICU). A total of 56 K. pneumoniae isolates were analysed. These included 10 bacteraemic isolates from eight patients, 26 isolates obtained during an epidemiological survey, and 20 epidemiologically non-related isolates incorporated as controls. One major pattern was demonstrated in 22 of the 56 isolates analysed. These included nine of the 10 bacteraemic isolates, a single rectal isolate, two hand culture isolates and 10 sink isolates. All of these 22 isolates illustrated identical antibiograms, whilst the other 34 isolates shared six antibiograms and 31 unique patterns by either PFGE or IRS-PCR assay. The two clusters of bacteraemia appeared to be outbreaks induced by the same strain of K. pneumoniae which may have utilized sinks as reservoirs and been transmitted through the hands of medical personnel to patients. IRS-PCR demonstrates concordant results with PFGE analysis in studying the genetic relationships among K. pneumoniae isolates, and serves as an excellent epidemiological tool for this bacterium.

Bacteremia↗

Strain relatedness of endemic MRSA isolates in a burns unit in South India--a five year study.

Methicillin-resistant Staphylococcus aureus (MRSA) is an important hospital-acquired pathogen in healthcare centres worldwide. The strain characteristics vary widely from country to country, although some strains have the propensity to spread globally. E-MRSA 15 and 16 have been established as epidemic strains in the UK and Europe. MRSA is widely prevalent in the Indian sub-continent and is endemic in the Burns Unit of St Johns Medical College Hospital, Bangalore, India. The purpose of the study was to investigate the predominance of one or more epidemic strains within an endemic situation. A representative selection of 65 isolates of MRSA over a period spanning five years (1994-1998) was subjected to antibiogram comparison, phage-typing and pulsed field gel electrophoresis (PFGE) using SmaI. The antibiogram comparison was not a discerning method of strain discrimination. At least 11 different phage-types were seen among these 65 isolates; 35.4% belonged to phage-types A and SM-A. PFGE studies showed 12 distinct patterns, with a single pattern accounting for over half of the isolates. The study showed that the isolates from India were diverse and distinct from strains of MRSA such as E-MRSA reported from many studies in the UK. Molecular characterization of isolates is a source of valuable information that could enhance global surveillance; more work is needed across the Indian sub-continent to establish the nature of MRSA strain diversity.

Bacteriophage Typing↗

Gram-negative bacterial toe web infection: a survey of 123 cases from the district of Cagliari, Italy.

BACKGROUND: Foot intertrigo is mostly caused by dermatophytes and yeasts, less frequently by gram-positive and gram-negative bacteria. Nevertheless, the importance of polymicrobial infections and especially colonizations of Pseudomonas aeruginosa can cause therapy problems in relation to antibiotic resistance and the risk of potentially lethal complications. OBJECTIVE: The aim of this study was to evaluate the main epidemiologic and clinical features of intertrigo from gram-negative bacteria, the function of promoting factors, and the measures taken to treat and prevent this disorder. METHODS: Between 1989 and 1998, 123 cases of intertrigo from gram-negative bacteria were observed at the Cagliari University Dermatology Department. Routine clinical and blood examinations, repeated bacterioscopic and mycologic examinations, cultures aimed at identifying the responsible bacteria, and antibiograms were performed. RESULTS: P aeruginosa was found to be the prevailing pathogen, both alone and associated with other gram-negative bacteria (such as Escherichia coli, Proteus mirabilis, Morganella morganii) and gram-positive bacteria. Clinical manifestations were similar in the majority of patients: erythema, vesicopustules, erosions, and marked maceration caused by abundant, malodorous exudate. Lesions affected the interdigital spaces of both feet and frequently extended to the planta and the back of the toes. Patients complained of burning and pain. Successful therapies were achieved with combined topical and systemic treatment; to avoid the risk of antimicrobial resistance, the choice of the active antibiotic was guided by antibiograms. CONCLUSION: In all symptomatic toe web infections, the presence of gram-negative germs, such as P aeruginosa, should be investigated to avoid the risk of treatment failures and more severe local or systemic complications.

Administration, Topical↗

Differences in antimicrobial susceptibility among hospitals in an integrated health system.

We evaluated the differences in antimicrobial susceptibility among hospitals in three different integrated healthcare systems. Each system provided antibiogram-susceptibility reports from representative hospitals. Reports were analyzed for statistically significant differences between hospitals in a given system for nine important organisms. We found numerous significant interhospital differences in antimicrobial-susceptibility patterns within health systems. For this reason, the practice of combining antibiotic-susceptibility data into a systemwide antibiogram should be discouraged.

Delivery of Health Care, Integrated↗

A longitudinal analysis of methicillin-resistant Staphylococcus aureus in a Hong Kong teaching hospital.

OBJECTIVES: To review the incidence and trends of MRSA during a 12-year (1989-2000) period at a university teaching hospital and the relationship between strain distribution by antibiogram and molecular typing. DESIGN: Retrospective review of laboratory-based surveillance records on MRSA isolation and characterization of strains by antimicrobial susceptibility and PFGE. A patient episode was counted at the time when MRSA was first isolated. SETTING: A 1,350-bed university teaching hospital in Hong Kong. PATIENTS: Those with clinical isolates of MRSA. RESULTS: During 1989 to 2000, the hospital recorded 1,203,175 deaths and discharges (D&D) and encountered 5,707 patient episodes of new MRSA isolation. The overall incidence of patient episodes of MRSA was 0.47/100 D&D. In 1989, the incidence was 0.81/100 D&D and fell to a low of 0.33/100 D&D in 1995, but then rose to 0.50/100 D&D in 2000. Antibiogram and DNA typing identified 5 major types. PFGE type A constituted 68% (211/312) of isolates and was present throughout the 12-year period. PFGE type B constituted 13% (40/312) of isolates and was only present from 1995 to 2000. These isolates form a distinct clone and had unique antibiotic resistance profiles. CONCLUSIONS: The study showed the establishment of a dominant MRSA clone (PFGE type A group) in the intensive care, medical, and surgical units and the appearance of a new MRSA strain in 1995 (PFGE type B), which partly explained the rise in incidence of MRSA cases and a disproportionate rise in MRSA bacteremia from 1995 to 2000.

Electrophoresis, Gel, Pulsed-Field↗

Nosocomial infections caused by Sphingomonas paucimobilis: clinical features and microbiological characteristics.

From January 1995 to September 1996, 14 isolates of Sphingomonas paucimobilis, including 11 from clinical specimens from six patients with nosocomial infection and three from environmental sources, were collected. Two of the six patients had intravascular catheter-related bacteremia and one each had bacteremic biliary tract infection, urinary tract infection, ventilator-associated pneumonia, and wound infection. The S. paucimobilis isolates were identified according to biochemical profiles established with use of the API 20NE system and Vitek GNI card and the characteristic cellular fatty acid chromatogram. Ten biotypes, 11 antibiograms (by the Etest), and 12 random amplified polymorphic DNA (RAPD) patterns (by arbitrarily primed polymerase chain reaction) were identified. The identical biotype, antibiogram, and RAPD pattern of the two isolates (one each from blood and bile) from a patient with biliary tract infection indicated the invasiveness of the organism. Two patients with intravascular catheter-related bacteremia had isolates of this organism repeatedly recovered, and these isolates had heterogeneous RAPD patterns. The present study highlights the wide distribution in hospital environments of various clones of S. paucimobilis, which may cause recurrent infections by a single strain or several episodes of infection due to two or more clones of this organism in hospitalized patients.

Adult↗

Oxacillin- and quinolone-resistant Staphylococcus aureus in Sao Paulo, Brazil: a multicenter molecular epidemiology study.

OBJECTIVE: To investigate the possibility of interhospital spread of multiresistant Staphylococcus aureus in Sao Paulo, Brazil. DESIGN: We evaluated 13 nosocomial S aureus strains selected because of resistance to oxacillin and ciprofloxacin. SETTING: The strains were collected between March 1991 and September 1991 from four different hospitals in Sao Paulo. Two were teaching hospitals, and two were private hospitals. PATIENTS: Each strain was isolated from a different patient. All patients were hospitalized when the strains were isolated. INTERVENTIONS: The strains were typed by restriction endonuclease analyses of plasmid DNA (REAP) using EcoRI, HindIII, RsaI, and AluI and by extended antibiogram profile (34 drugs). RESULTS: All strains had identical plasmid and antibiogram profile. They demonstrated the same plasmid pattern as previously described in one of the hospitals studied. CONCLUSIONS: Our results suggest the dissemination of a unique oxacillin- and quinolone-resistant strain of S aureus in several hospitals of Sao Paulo, Brazil.

Bacterial Typing Techniques↗

Nosocomial transmission of Serratia odorifera biogroup. 2: Case report demonstration by macrorestriction analysis of chromosomal DNA using pulsed-field gel electrophoresis.

OBJECTIVES: To investigate a cluster of Serratia odorifera in a cardiothoracic surgery unit (CTSU) and to evaluate the applicability of three typing methods for this species. DESIGN: During a surveillance surgical wound study, S odorifera was isolated from two patients in the CTSU. The patients' hospital charts were reviewed for the details of surgery and for common personnel, procedures, or medications. Cultures were obtained of water, soap, and unit dose medications from the CTSU, the operating room, and the surgical intensive care unit. The isolates' antibiograms, biotypes (Vitek identification card and API 20E), and patterns of chromosomal DNA (chrDNA) by pulsed-field gel electrophoresis (PFGE) were examined. S odorifera isolates from our organism collection were used as controls. SETTING: A 900-bed university hospital with a 22-bed CTSU. RESULTS: ChrDNA patterns of isolates from the two patients were identical, suggesting a possible nosocomial source. However, no source of organisms or mode of transmission was identified. Neither biotype nor antibiogram were useful for epidemiologically typing S odorifera, and PFGE was necessary to discriminate among isolates. CONCLUSIONS: Although rarely isolated, S odorifera and other non-marcescens Serratia species may cause nosocomial outbreaks. PFGE of chrDNA seems to be a reliable method for epidemiologically typing this species.

Aged↗

Characterization of antimicrobial resistance, plasmids, and gene cassettes in Shigella spp. from patients in vietnam.

The objective of the study was to investigate antimicrobial resistance, plasmids and class 1 integrons in 150 Shigella strains isolated from patients with diarrhea in Vietnam. Most isolates were resistant to the majority of antimicrobial agents used for treatment in the isolation areas and 90% were resistant to three or more antibiotics. A total of 20 strains yielded class 1 integrons, which harbored oxa1, dfrA, orfF, and aadA gene cassettes. The most common gene cassette, aadA2, was always located closest to the 3' conserved segment of the integrons and oxa1 and dfrA closest to the 5' end. Plasmid profiles of the 20 class 1 integron-positive strains all contained more than one plasmid, and 14 different profiles were found. No correlation was found between species, antibiograms, plasmid profiles, or presence of class 1 integrons. Conjugation resulted in 25 transconjugants, which all were resistant to four or more antimicrobial agents and all harbored at least one plasmid (>60 kb). Class 1 integrons were detected in 64% of the transconjugants. Phenotypic resistance pattern and plasmid profiles of the transconjugants seemed independent of the presence of an integron. Class 1 integrons seemed of less importance in phenotypic antibiograms and in transfer of resistance genes than conjugative plasmids.

Anti-Bacterial Agents↗

Molecular analysis of viridans and nutritionally deficient (variant) streptococci causing sequential episodes of endocarditis in a patient.

Clinical blood isolates from sequential episodes of endocarditis occurring over a six-month period of time in an addict were investigated. The pathogens were Streptococcus sanguis II, Streptococcus mitis, and a nutritionally deficient (variant) streptococcus. The authors determined the DNA relatedness of these isolates by antibiograms, plasmid profiles, chromosomal endonuclease restriction digestions, and dot blot DNA-DNA hybridization analyses. The S. sanguis II and nutritionally deficient streptococcal strain had similar antibiograms being resistant to penicillin; neither produced beta-lactamase. No plasmids were found. The restriction endonuclease chromosomal digestion patterns of these isolates were unique and epidemiologically unrelated to each other. Dot blot DNA-DNA hybridizations, using the nutritionally deficient streptococcal DNA as the probe, showed homology to the preceding clinical isolates, S. sanguis II and S. mitis, at 15.4% and 45.1% hybridization levels, respectively. The nutritionally deficient streptococcus was only 4.2% homologous to a S. mitis ATCC strain and another nutritionally deficient streptococci isolate. Therefore, this patient had endocarditis with three distinct streptococcal strains.

Adult↗

Instability of antibiotic resistance in a strain of Staphylococcus epidermidis isolated from an outbreak of prosthetic valve endocarditis.

Plasmid profiles, phage typing, antibiograms, and biotyping were used to characterize Staphylococcus epidermidis isolated from multiple cultures of blood of four patients with prosthetic valve endocarditis. Epidemiological evidence implicated a common source for these infections. Of 20 clinically significant isolates, 14 exhibited variations from the prototype pattern of multiple resistance to five antibiotics. All isolates tested appeared to be the same strain by phage typing. Of 18 isolates available for plasmid analysis, 10 contained six plasmids of identical size, whereas eight differed from the prototype profile in the loss of one to three plasmids. Loss of resistance to gentamicin, chloramphenicol, erythromycin, and clindamycin but not to methicillin was associated with the loss of specific plasmids. Because antibiotic resistance in this strain of S. epidermidis was unstable, the use of antibiograms alone was not a reliable means of evaluating the relatedness of these multiple isolates.

Anti-Bacterial Agents↗

Interpretative reading: recognizing the unusual and inferring resistance mechanisms from resistance phenotypes.

If isolates are speciated and if a sufficient range of antibiotics is tested, underlying resistance mechanisms can often be inferred from the antibiogram data. This allows: (i) anomalous combinations of phenotype and organism to be reconsidered; (ii) prediction of further antibiotics that deserve testing; and (iii) the suppression of susceptibilities that are anomalous in the light of the inferred mechanism. This 'interpretative reading' is widely undertaken in France but is largely precluded in the UK by limited speciation and the testing of narrow ranges of antibiotics. Nevertheless, UK laboratories should be aware of: (i) grossly anomalous combinations of species and phenotype, demanding reference laboratory confirmation; (ii) useful indicator drugs, where resistance implies a mechanism conferring other resistances that may be less obvious in direct tests; and (iii) antibiotics that are prone to select resistant mutants of particular species during therapy. Details of these combinations of organism and resistance are presented. Relationships between antibiogram and mechanism are also presented to allow full interpretative reading for those testing wide panels of drugs versus speciated isolates.

Aminoglycosides↗

Phenotypic variability of Pseudomonas aeruginosa in sputa from patients with acute infective exacerbation of cystic fibrosis and its impact on the validity of antimicrobial susceptibility testing.

OBJECTIVES: To investigate the variability in antimicrobial susceptibility of Pseudomonas aeruginosa from sputa of patients with cystic fibrosis, to compare testing individual colonies of the same morphotype either separately or combined and to study the reproducibility of testing antimicrobial susceptibility within and between laboratories. METHODS: One hundred and one sputa were cultured. Four colonies of each P. aeruginosa morphotype were suspended. Susceptibility to 12 agents by disc diffusion was tested individually or by pooling the four suspensions. A sputum sample containing four morphotypes of one genotype of P. aeruginosa was used to study reproducibility. Susceptibility was tested in duplicate by eight biomedical scientists in one laboratory and by routine procedures in seven different laboratories. RESULTS: There was a mean of four morphotypes of P. aeruginosa per sputum and three antibiograms per morphotype. In some cases, all four colonies of a single morphotype had different antibiograms. The susceptibility profiles of single isolates of P. aeruginosa correlated poorly with pooled cultures, with the pooled tests missing resistance. Results from one sample tested in duplicate by eight biomedical scientists in one laboratory and in seven other laboratories did not correlate well. The wide range of zone sizes in disc diffusion tests illustrated the variation in susceptibility of 48 colonies from one sputum sample. CONCLUSIONS: The role of conventional antimicrobial susceptibility testing is questionable once P. aeruginosa chronically infects the cystic fibrosis lung. A range of susceptibility patterns is seen, even within a morphotype. Routine test results are not reproducible and underestimate resistance.

Acute Disease↗

Carriage of class 1 integrons and antibiotic resistance in clinical isolates of Acinetobacter baumannii from northern Spain.

A collection of 70 clinical isolates of Acinetobacter baumannii from Bilbao in northern Spain was examined by PCR for the presence of class 1 integron structures. The organisms comprised 21 distinct RAPD genotypes, with 10 distinct antibiogram patterns. Four different integron structures were detected in a total of 59 (84%) of the 70 isolates, with two predominant integron structures found in 20 and 30 isolates each. No clear antibiogram differences could be correlated with the presence or absence of integron structures, but sequence analysis of two of the internal integron regions indicated homology with genes encoding ANT(2'') adenyltransferase activity and AAC(6')-Ib acetyltransferase activity. Phenotypic analysis of aminoglycoside resistance profiles indicated that many isolates produced a combination of aminoglycoside-modifying enzymes, with most of the observed resistance to amikacin being associated with a gene encoding APH(3')-VI phosphotransferase, as detected by PCR. RAPD analysis indicated that all the Bilbao isolates producing APH(3')-VI were distinct from an epidemic integron-carrying and APH(3')-VI-producing Acinetobacter strain found in other regions of Spain. It is concluded that, although class 1 integrons are widely disseminated amongst clinical isolates of A. baumannii from the Bilbao region of Spain, at present they are not playing a major role in the dissemination of antibiotic resistance genes in this region.

Acinetobacter↗

The evaluation of a typing scheme for coagulase-negative staphylococci suitable for epidemiological studies.

A typing scheme was devised for an epidemiological study of infection with coagulase-negative staphylococci in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). The scheme was constructed in four stages suitable for the screening of large numbers of isolates: antibiogram, biotype, phage type, and plasmid profile. The discrimination and reproducibility of the scheme was established by the examination of 50 isolates from 33 consecutive episodes of peritonitis affecting 18 patients. The discrimination of the scheme was 76%, with a reproducibility of 86%. Indistinguishable strains occurred in individual patients only, demonstrating that no cross-infection between patients occurred during the 10-month period of collection of strains, and suggesting that the discriminating power of the scheme was, in fact, much higher. The antibiogram, selected as the first stage of the scheme because it was the simplest and cheapest test, proved to be the most discriminatory stage, providing 60% of the final discriminatory power.

Anti-Bacterial Agents↗

An investigation of a nosocomial outbreak of Clostridium difficile by pyrolysis mass spectrometry.

Isolates from a presumptive nosocomial outbreak of Clostridium difficile infection at a large teaching hospital were typed by pyrolysis mass spectrometry (PMS) and antibiograms. One isolate, from the putative index case, was dissimilar from the outbreak strain, but 24 isolates from 16 patients were indistinguishable by both methods. The outbreak centred on two wards for the acute care of the elderly, with a few cases elsewhere. Transfer of patients appeared to be the route of transmission between wards. There was a significant fall in the incidence of cases following intervention by the Infection Control Unit. This included ward inspection, advice on antibiotic usage and advice on prevention of faecal-oral transfer, particularly by proper handwashing. Subsequent monitoring of C. difficile infection showed a background of sporadic, dissimilar isolates with occasional apparent cross-infection incidents limited to a few patients. In suspected outbreaks, patterns of antibiotic susceptibility may be useful in initial screening, before referral for more sophisticated typing. There was excellent correlation between PMS results, antibiograms and epidemiological information.

Aged↗