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Evaluation of staphylococci isolated from a blood culture system (Colorbact).

During a one-year period, all blood cultures positive for staphylococci from two of the smaller Danish counties with non-university hospitals only were evaluated. The isolates were speciated and coagulase-negative staphylococci (CoNS) were biotyped. Furthermore, antibiogram, phage typing and lectin typing were performed for all isolates. Clinical information was obtained by telephone, and before any bacteriological identification was performed, a preliminary judgment was made as to whether the positive blood culture was of clinical significance. A total of 3,500 blood cultures were evaluated and 426 (12.2%) were positive. One hundred and sixty blood cultures from 137 patients contained staphylococci; 36 of these patients had a pure culture of Staphylococcus aureus. One hundred and twenty-four CoNS were found and identified as S. epidermidis (81), S. hominis (19), S. haemolyticus (8), S. simulans (1), and Micrococcus species (3), and another 12 staphylococcal isolates which could not be identified to species level. A total of 35 patients had mixed cultures, including 6 with S. aureus as one of the isolates and 15 with mixed CoNS. Clinical relevance was estimated in 90% of cases where the later bacterial identification showed S. aureus, whereas clinical relevance was absent in the majority of cases including CoNS. Methicillin and gentamicin resistance was absent among S. aureus, but frequent among CoNS, especially S. epidermidis, where 40% were resistant to methicillin and 30% to gentamicin.

Bacteremia↗

Antibiotic susceptibility of blood culture isolates after nearly two decades with netilmicin and ampicillin in neonatal septicaemia.

The aim of the study was to investigate the in vitro antibiotic susceptibility of blood culture isolates after almost 20 years with ampicillin and methicillin as empirical treatment for neonatal septicaemia. All blood culture isolates and their antibiograms obtained in a single tertiary neonatal intensive care unit from 1 January 1989 to 31 December 1994 were reviewed. Two hundred and six blood cultures from 181 infants containing 223 bacterial and 11 fungal isolates were identified during 4416 admissions. Fifteen (6.7%) of the bacterial isolates were resistant to ampicillin and netilmicin. Fourteen per cent of the staphylococcal spp. were susceptible to penicillin while more than 90% were susceptible to netilmicin. The coagulase-negative staphylococci (CONS) were resistant to netilmicin, methicillin and gentamicin in 12%, 49% and 65%, respectively. Eighty-nine per cent of the methicillin-resistant CONS were susceptible to netilmicin as opposed to 17% to gentamicin (p<0.001). Except for one strain of Acinetobacter sp., all Gram-negative bacteria were susceptible to netilmicin. Our data show that the ampicillin-netilmicin combination still provides a high in vitro coverage (93%) against bacteria identified in blood cultures from newborns in our unit. Netilmicin has a significantly better in vitro effectiveness against CONS than gentamicin.

Ampicillin↗

Topical antibiotic ear drops: are they safe?

A discharging ear is a very common condition for the general practitioner and the ENT surgeon. Oral and intravenous antibiotics have potential complications, are costly, and exhibit increasing resistance. This study explores the advantages and disadvantages of all common otic preparations and compares effectiveness, safety, cost and complication rates. In chronic otitis media (chronic discharging ears), topical antibiotics seem to be the treatment of choice by comparison with oral or intravenous antibiotics. Cultures and antibiograms do not correspond directly to clinical efficacy, as laboratory determination of resistance does not take into account the high concentration of antibiotics in local preparations. It is safer to use quinolone drops as a first-line treatment, but it is still possible to use short courses of other drops if quinolones are either unavailable or contraindicated (e.g. allergy), or when bacteria are resistant to them. However, in such a situation, a round window membrane involved in an established inflammatory process and therefore less permeable to the passage of topical preparations is the preferred setting, as ototoxicity is a potential complication, especially in the case of gentamicin, in which case patients should be warned accordingly.

Administration, Topical↗

[Plasmid profiles of aminoglycoside-resistant Pseudomonas aeruginosa].

Three-hundred and eighty-five strains of Pseudomonas aeruginosa were isolated from Gunma University Hospital from 1984 to 1987. Out of these strains, thirty strains (7.8%) were resistant to GM. We investigated antibiograms, serotyping, phage typing, and plasmid profiles of these strains. The following results were obtained. 1) Only one kind of GM-resistant (GMr) plasmid was obtained in 1984. Two kinds of GMr plasmids were found in 1985, and three kinds of GMr plasmids in 1987, respectively. 2) A strain of I-serotype and Hh8-phage type containing the plasmid I (GM-SM-SA-PIPC, Tra-, 22.6Kb or 22.5 Kb) was suspected to cause the nosocomial infection mainly in Departments of Internal Medicine, and a strain of non-serotypable and Hh8-phage type containing the plasmid IV (GM-SM-SA-CP-Hg, Tra+, IncP-2) was suspected to cause the nosocomial infection mainly in Surgical Departments. 3) Plasmid profiles adding to serotyping and phagetyping contribute to the epidemiological analysis of Pseudomonas aeruginosa infection.

Aminoglycosides↗

[Characterization of Salmonella ser. enteritidis phage type 34 isolated from food poisoning outbreaks in Tokyo by epidemiological makers].

Since 1989, outbreaks of Salmonella ser. Enteritidis food poisoning has dramatically increased in Tokyo, and a total of 95 outbreaks has been reported between 1989 and 1993. As the results of examination of phage type by the method of Ward, et al., strains isolated from 31 (32.6%) of 95 outbreaks were phage type 34 which is a very rare type in Europe and America. To characterize these unique strains of phage type (PT) 34, 302 isolates obtained from patients and vehicle foods of the outbreaks, eggs and environments in Tokyo were examined for plasmid DNA profiles and antimicrobial resistance patterns. Plasmid DNA was extracted by the Kado's method, and analysed by agalose gel electrophoresis. Antimicrobial susceptibility was tested for CP, TC, SM, KM, ABPC, NA, SXT, FOM and NFLX by the K-B disc method. The strains of PT 34 were further subdivided to 4 types by plasmid profile and antibiogram. The prevalent pattern of PT 34 strains was type plasmid profile which carried 2 different plasmids (> 250 and 60 kb) and was streptomysin-resistant. A total of 28 (90.3%) of 31 outbreaks were found to be caused by this specific type of Salmonella ser. Enteritidis. Several kinds of egg-related foods were suspected for the vehicles of transmission among 12 outbreaks. Especially, in 5 outbreaks, this specific type (type B plasmid profile and streptomysin resistant) of Salmonella ser. Enteritidis strains were isolated both from patients and incriminated food which were cooked with eggs. The phase type of Salmonella ser. Enteritidis strains isolated from raw egg and poultry or environmental specimens from poultry farm showed that the prevailing phage types were almost the same as those of foods poisoning outbreaks. This strongly suggests that these foods may be considered as a source of infection in Salmonella ser. Enteritidis outbreaks.

Anti-Bacterial Agents↗

[Biochemical and molecular characterization of Salmonella serovar enteritidis phage type 4 isolated from food poisoning outbreaks in Tokyo].

Since 1989, outbreaks of Salmonella ser. Enteritidis (S. Enteritidis) food poisoning have dramatically increased in Tokyo, and a total of 31 outbreaks has been reported in 1989. Twenty-one of these 31 outbreaks were caused by S. Enteritidis PT34, but 8 outbreaks were caused by S. Enteritidis PT4. After 1990 instead of SE PT34, food poisoning due to PT4, which was a very common phage type in the UK, has increased in Tokyo. Between 1989 and 1995, there were 144 food poisoning outbreaks caused by S. Enteritidis, and 64 of these outbreaks were by due to S. Enteritidis PT4, which was one of the main phage types in Tokyo. To characterize these strains of phage type (PT) 4,293 isolates from patients, and vehicle foods, eggs and environment in Tokyo were examined for plasmid DNA profiles, acid productivity from glycols (propylene and ethylene) and antimicrobial resistance patterns. Plasmid DNA was extracted by Kado's method, and analyzed by agarose gel electrophoresis. The acid productivity from propylene glycol or ethylene glycol were tested using Barsicow medium with 1% propylene glycol or ethylene glycol. Antimicrobial susceptibility to AM, CP, TC, SM, KM, NA, ST, FOM and NFLX was tested by the K-B disc method. The strains of PT4 were further subdivided into 9 types by those epidemiologic marker analysis. The prevalent pattern of PT4 strains was type A plasmid profile carrying only one plasmid (60 kb) and there were 2 kinds of antibiograms. One was SM resistant, while the other was susceptible. A total of 56 (87.5%) of 64 outbreaks was found to have been caused by these types of S. Enteritidis. Several kinds of egg-related foods were suspected as the vehicles of transmission among 24 outbreaks. Especially, in 5 outbreaks, S. Enteritidis strains were isolated both from patients and suspected food which were cooked with egg. This strongly suggests that these foods may be the potential source of infection in S. Enteritidis PT4 outbreaks.

Anti-Bacterial Agents↗

[Analysis of utility of the phenotyping method on detection of cases infected by multiple strains of methicillin-resistant Staphylococcus aureus (MRSA)].

In this study, we compared the types of methicillin-resistant Staphylococcus aureus (MRSA) isolated from several foci of the same patient to find the incidence of multiple strain infection of MRSA in bacteremia cases. We will also evaluate the utility of the typing methods of phenotyping and genotyping for the above mentioned objective and judge the dissimilarity of clinical characteristics between the single strain infection and multiple strains infection. We studied 21 cases of MRSA bacteremia who were culture-positive both from blood and other foci in the same patient at Nagasaki University Hospital during 1990-1994. Clinical data were retrospectively collected from the patients' records. Phenotyping of all 113 MRSA isolates were done by coagulase typing (I-VIII), production of enterotoxins (SEA-SED) and toxic shock syndrome toxin-1 (TSST-1), hemolysis typing and antibiogram (MIC). In addition, typing of the same isolates were done by Pulsed-Field Gel Electrophoresis (PFGE), using Gene Navigator System as the genotyping. Several types of MRSA were found from different foci in the same patient in 8 of 21 cases (38%) by phenotyping. The same typing results were obtained in 7 of 8 the multiple strains isolated cases by PFGE. Two types were obtained from another case by phenotyping, but by PFGF, 3 types were obtained. We consider that phenotyping method is convenient and reliable for judgment of the difference in types isolated from different foci in the same patient, but PFGE possibly provide us more detailed epidemiological information. The epidemiological investigation must be done very carefully, especially in immunocompromised hosts as MRSA bacteremia cases, because the chance of multiple strains infection is relatively high among these cases.

Bacteremia↗

[Comparison of epidemiological markers for Vibrio parahaemolyticus isolated from food poisoning].

Vibrio parahaemolyticus food poisoning, is the most prevalent among bacterial food poisoning in Japan. Study of epidemiologic markers is important in an attempt to trace the source of contamination. The purpose of this study was to compare seven different typing methods (serotyping, plasmid profile, antibiogram, phage susceptibility. TDH production, tdh and trh gene and pulsed-field gel electrophoresis [PFGE]) for V. parahaemolyticus. Outbreaks of V. parahaemolyticus food poisoning which occurred during the 13 years from 1981 to 1993 numbered 43 including 481 cases in Nagano Prefecture. Serovar O4:K8 was the most prlevalent serovar isolated, serovar O2:K3, O4:K63 and O3:K5 followed. Forty one strains of V. parahaemolyticus were used in this study. All of the strains were isolated from 12 food poisoning cases at Nagano Prefectual Research Institute for Health and Pollution. Of the 41 strains, twenty two strains (O4:K8, O4:K63) were sensitive to both phi VP 253 and phi VP 143 phages, six strains (O3:K5) to phage phi VP 143. Thirteen strains (O3:K29, O4:K11, O4:K12 and O5:KUT) were insensitive to both phages. CBPC, CBPC.CEZ and CBPC.CEZ.KM.SM resistant strains was determined in 22 strains out of 41 strains. Five strains of V. parahaemolyticus carried plasmid. Of the 41 strains, thirty nine strains were possessive to tdh gene and productive to TDH. Chromosomal DNA of the isolates from 12 different outbreaks was analysed by PFGE after Not I digestion. PFGE analysis of the digested DNA yielded 11 to 21 DNA fragments. Twelve distinctive fragment patterns were identified in 41 V. parahaemolyticus isolates from 12 different food poisonings. These results showed that the PFGE method is an useful tool to analyse an epidemiological survey for isolates of Vibrio parahaemolyticus food poisoning.

Electrophoresis, Gel, Pulsed-Field↗

Molecular typing of methicillin-resistant Staphylococcus aureus in a university teaching hospital.

Plasmid analysis and pulsed-field gel electrophoresis (PFGE) were used to study the epidemiologic relationship among methicillin-resistant Staphylococcus aureus (MRSA) strains isolated at Tokyo Medical and Dental University Hospital. We found that 263 of 276 MRSA isolates had plasmids, which could be classified into 30 different patterns according to the number and plasmid molecular weight. Strains which harboured a single plasmid of approximately 13.4 Mds in molecular weight were the most numerous (55.7% of the isolates). These strains were isolated from 14 of 17 hospital wards. The largest number of strains with this plasmid pattern (33 strains) were isolated from a single ward. PFGE typing was then performed to further confirm the relationships among these 33 strains. The PFGE banding patterns of these strains were highly similar. The antibiogram profiles of these strains were also correlated with the PFGE pattern. Thus, the results suggest that these strains are epidemiologically related and spread throughout the ward. Combined plasmid analysis and PFGE were effective for discriminating the various MRSA isolates.

DNA, Bacterial↗

[Hospital-acquired Streptococcus pneumoniae infection].

Three elderly patients were consecutively found to harbor or to become infected with intermediate-level penicillin-resistant Streptococcus pneumoniae in a hospital respiratory ward. All the isolates from the respective patients produced mucoid-type colonies on sheep blood agar plates and were found to have an identical antibiogram, indicating that those were resistant against erythromycin, clarithromycin, clindamycin and minocycline. Pulse-field gel electrophoresis of genomic DNA digested Sma I and Apa I demonstrated homology among the isolates, which may suggest person-to-person spread in a hospital setting. With this, it is an urgent to establish the institution-based infection control precautions against S. pneumoniae.

Aged↗

Physical characterization of ten R plasmids obtained from an outbreak of nosocomial Klebsiella pneumoniae infections.

Gentamicin resistance in Klebsiella pneumoniae involved in an outbreak at the Minneapolis Veterans Administration Hospital was due to a transmissible R plasmid. In addition to gentamicin, this plasmid conferred resistance to tobramycin, kanamycin, ampicillin, carbenicillin, cephalothin, chloramphenicol, and sulfathiazole. R plasmids which transferred this complex antibiogram were identified in several clinical isolates, including four different serotypes of K. pneumoniae, Escherichia coli, Enterobacter cloacae, and Proteus morganii. The covalently closed circular form of all R plasmids isolated had a sedimentation coefficient of 76S to 77S, corresponding to a molecular weight of 58 x 10(6). The possibility that a single R plasmid was responsible for the dissemination of multiple drug resistance among all of these different clinical strains was examined by characterizing the plasmids by using EcoRI restriction endonuclease. The same 15 fragments were obtained from each of the 10 plasmids analyzed. Their molecular weights ranged from 4 x 10(5) to 11 x 10(6). Thus, we conclude that each of the 10 plasmids present in the various clinical strains isolated from the hospital over a 7-month period originated from a common source and that R plasmid transfer was important in their spread.

Anti-Bacterial Agents↗

Antimicrobial susceptibility of Campylobacter jejuni and Campylobacter fetus subsp. fetus to eight cephalosporins with special reference to species differentiation.

Agar dilution antimicrobial susceptibility testing showed that Campylobacter jejuni was significantly more resistant than Campylobacter fetus subsp. fetus (intestinalis) to cephalosporin C, cephaloridine, cephalothin, cefazolin, and cefamandole. No species differences in susceptibility were noted with cephalexin, cefotaxime, and cefoxitin. Rapid species differentiation on the basis of an antibiogram could be achieved with the disk diffusion method. C jejuni failed to produce a zone of inhibition around a 30-microgram cephalothin disk but produced a significant zone around a 30-microgram nalidixic acid disk. C. fetus subsp. fetus (intestinalis) produced exactly the reverse pattern.

Campylobacter↗

Development of resistance to cephalosporins in clinical strains of Citrobacter spp.

The predominant beta-lactam antibiogram of Citrobacter freundii resembles that of Enterobacter cloacae in demonstrating resistance to cephalothin and cefoxitin with susceptibility to the newer cephalosporins. Four representative strains of C. freundii were reversibly induced to high-level beta-lactamase production by cefoxitin, and mutants with stable, high-level production were selected with cefamandole. The mutants were resistant to several second- and third-generation cephalosporins. Comparisons of isoelectric points and substrate profiles of beta-lactamases from wild-type, induced wild-type, and mutant organisms suggested a close relationship to those from E. cloacae and indicated that C. freundii mutants, like those of E. cloacae, were derepressed for production of beta-lactamase. One primary isolate of C. freundii resembled the mutants in all characteristics. In contrast, most strains of Citrobacter diversus were susceptible to all cephalosporins, and two representative strains showed neither inducible nor mutational resistance. Cefoxitin induction to enhanced beta-lactamase production was demonstrated in a cephalothin-resistant isolate, and a derepressed mutant was selected with cefotaxime. The beta-lactamase from this C. diversus strain differed substantially in substrate profile from that of E. cloacae and C. freundii.

Cephalosporins↗

Does prolonged exposure to antibiotic-resistant bacteria increase the rate of antibiotic-resistant infection?

The magnitude of the risk of acquiring infections due to antibiotic-resistant bacteria, as a consequence of prolonged contact with such bacteria, is unclear. We compared antibiotic resistance patterns of Escherichia coli isolated from the urine of bacteriuric female abattoir workers with resistance patterns of E. coli cultured from 190 poultry taken from the processing line. We found E. coli in 181 (95%) of the poultry cultures; 96% of the isolates were resistant to one or more antibiotics, and 87% were multiply resistant. Of the 649 women whose urine was cultured and who had not recently received antibiotic therapy, 69 (10.6%) had positive urine cultures, with E. coli accounting for 67% of the isolates. Of the 46 E. coli isolates, 8 (17.4%) were resistant to one or more antibiotics. All of the antibiograms of the urinary isolates were unique, and only one, a strain with resistance only to streptomycin, matched those of any of the poultry isolates. Of the women tested for bacteriuria, 74 had taken antibiotics within 3 months of culture, and these women were analyzed separately. Among the recent antibiotic users, six (8.1%) had positive urine cultures, all with E. coli. Four of these isolates were resistant to at least one antibiotic; all had patterns that matched at least one of the poultry isolates. Therefore, in a population of female abattoir workers who were not receiving antibiotic therapy, despite a high exposure to resistant microorganisms of animal origin, infections were infrequently caused by organisms with resistance patterns characteristic of the livestock to which the women were heavily exposed.

Abattoirs↗

Low-level colonization of hospitalized patients with methicillin-resistant coagulase-negative staphylococci and emergence of the organisms during surgical antimicrobial prophylaxis.

By use of techniques that have been developed to detect small numbers of methicillin-resistant staphylococci, we cultured samples from the nares and subclavian and inguinal areas of 29 patients before and after cardiac surgery and 10 patients before and after coronary angioplasty. Methicillin-resistant coagulase-negative staphylococci were recovered before the surgical or angioplasty procedure from 74% of patients. The quantitative recovery of methicillin-resistant isolates before cardiac surgery or coronary angioplasty was compared with the number of methicillin-resistant staphylococci detected at the same site 3 days after the procedure. In cardiac surgery patients (who received antibiotic prophylaxis), 17 of the 28 sites (61%) in which low-level colonization with methicillin-resistant strains was detected preoperatively contained high levels of methicillin-resistant staphylococci postoperatively. In contrast, coronary angioplasty patients (who did not receive antibiotic prophylaxis) did not have any of the 14 sites containing low levels of methicillin-resistant strains before angioplasty emerge to harbor high levels of methicillin-resistant staphylococci after angioplasty. Methicillin-resistant coagulase-negative staphylococci from each site in which high levels of methicillin-resistant staphylococci emerged postoperatively were paired with preoperative isolates from the same site. Identical antibiograms and plasmid profile patterns were demonstrated for seven of the pre- and postoperative isolate pairs, suggesting that the high levels of methicillin-resistant coagulase-negative staphylococci detected on the skin or in the nares after cardiac surgery were derived from methicillin-resistant organisms present at the site preoperatively in much smaller numbers.

Angioplasty, Balloon↗

Novel plasmid-mediated beta-lactamase (TEM-10) conferring selective resistance to ceftazidime and aztreonam in clinical isolates of Klebsiella pneumoniae.

Two clinical isolates of Klebsiella pneumoniae from seriously ill patients in Chicago, Ill., have been identified as resistant to ceftazidime and aztreonam but susceptible to other cephalosporins. This unusual antibiogram was shown to be due to a novel plasmid-mediated beta-lactamase which readily hydrolyzed ceftazidime and aztreonam in addition to penicillins such as piperacillin and carbenicillin. This enzyme and its attendant resistance were transferred to Escherichia coli by conjugation on a 50-kilobase plasmid. Isoelectric focusing revealed a single beta-lactamase band with a molecular weight of 29,000 and an isoelectric point of 5.57 in the resistant isolates and transconjugants. The beta-lactamase inhibitors clavulanic acid and sulbactam restored beta-lactam susceptibility in the resistant isolates. Fifty percent inhibitory concentrations of clavulanic acid and sulbactam were 4.4 and 940 nM, respectively. DNA hybridization studies indicated that this enzyme, designated TEM-10, is related to well-established TEM-type beta-lactamases. However, the TEM-10 enzyme was inhibited by p-chloromercuribenzoate, in contrast to TEM-2 beta-lactamase. On the basis of substrate and inhibition profiles, the TEM-10 enzyme could be easily discriminated from TEM-5 and RHH-I beta-lactamases.

Anti-Bacterial Agents↗

Comparison of in vitro antimicrobial susceptibilities of Mycobacterium avium-M. intracellulare strains from patients with acquired immunodeficiency syndrome (AIDS), patients without AIDS, and animal sources.

Difloxacin, A-56620, cefazolin, cefotaxime, ceftizoxime, cephapirin, SK&F 88070, and spectinomycin were used to compare the in vitro susceptibilities of Mycobacterium avium-M. intracellular isolates from patients with acquired immunodeficiency syndrome (AIDS), patients without AIDS, and diseased animals. Against the isolates from humans without AIDS, the quinolone compounds difloxacin and A-56620 were found to be the most effective, each inhibiting 50% of strains at a concentration of 2 micrograms/ml. The remaining antimicrobial agents had MICs for 50% of strains tested of at least 32 micrograms/ml. Statistically significant differences were observed in the antibiogram patterns among the M. avium-M. intracellulare strains from each of the three sources.

Acquired Immunodeficiency Syndrome↗

Eradication of colonization by methicillin-resistant Staphylococcus aureus by using oral minocycline-rifampin and topical mupirocin.

In an attempt to control the spread of methicillin-resistant Staphylococcus aureus (MRSA) within a spinal cord injury unit, we investigated the mode of transmission and implemented a multidisciplinary approach for control that consisted of grouping of patients into cohorts, contact isolation, and antibiotics. Surveillance cultures of patients and nose and hand cultures of medical personnel were performed. Of 11 colonized patients, 6 had MRSA isolates that shared a similar plasmid profile and antibiogram, raising the possibility of interpatient spread of the organism. Medical personnel had no evident role in transmitting MRSA. All patients' pretherapy MRSA isolates were susceptible to minocycline and, except for one, to rifampin. Time-kill studies showed an indifferent interaction of these two antibiotics. Ten colonized patients received a 2-week oral course of 100 mg of minocycline twice daily and 600 mg of rifampin once daily, while the 11th patient was treated for only 1 week. Patients with colonization of the nares also had twice daily nasal application of 2% mupirocin for 5 days. Colonization with MRSA cleared in 10 of 11 patients (91%) and 20 of 21 sites (95%). When the individual circumstances of a medical facility justify eradication of MRSA colonization, a multidisciplinary approach that includes antibiotic therapy with oral minocycline and rifampin, along with topical mupirocin for those with nasal carriage, may be successful.

Administration, Oral↗