The Control of Methicillin-Resistant Staphylococcus aureus Blood Stream Infections in England.

Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infection (BSI) is a major healthcare burden in some but not all healthcare settings, and it is associated with 10%-20% mortality. The introduction of mandatory reporting in England of MRSA BSI in 2001 was followed in 2004 by the setting of target reductions for all National Health Service hospitals. The original national target of a 50% reduction in MRSA BSI was considered by many experts to be unattainable, and yet this goal has been far exceeded (∼80% reduction with rates still declining). The transformation from endemic to sporadic MRSA BSI involved the implementation of serial national infection prevention directives, and the deployment of expert improvement teams in organizations failed to meet their improvement trajectory targets. We describe and appraise the components of the major public health infection prevention campaign that yielded major reductions in MRSA infection. There are important lessons and opportunities for other healthcare systems where MRSA infection remains endemic.

Contribution of a government target to controlling Clostridium difficile in the NHS in England.

The introduction of mandatory surveillance of Clostridium difficile infection (CDI) in 2004 showed the scale of the challenge: cases in patients >64 years old reached 55,681 in 2006. The first type 027 outbreaks had been in 2005 and CDI was a headline issue. The prevention and control of CDI requires a tripartite partnership between clinicians, health service managers, and the government/Department of Health which needs to set standards, ensure that CDI is a priority, set targets and monitor outcome. Government can also legislate; the Health Act 2006 introduced a statutory Code of Practice for infection prevention and control for the NHS and extended to all independent health and care settings in 2010. In 2008, a national target was set for a 30% reduction in CDI by 2010-11 (baseline 2007-8). It was population-based and set a standard (ceiling) rate/10,000 in each area, within which acute hospitals had a target/1000 admissions (diagnosed after day 3). In the first year (2008-9), a 35% reduction was achieved from 55,499 to 36,079 cases in all ages and in 2009-10 the total was 25,604, a 54% reduction from 2007-8. However, in 2009, cases >64 years old were 29% down from 2008 but only 9% down in the 2-64 year old group; also, by this stage, cases in acute hospitals and in other settings were almost equal. Death certification showing CDI fell for the first time in 2008 and in 2009 there were 3550 total mentions (7816 in 2007) of which 1510 (42%) were as underlying cause (3875, 49%, in 2007). The reductions in CDI have been achieved by a raft of measures. Crucially, the targets focused management emphasis on infection prevention and control. This was supported by enhanced surveillance. Clinical practice protocols were implemented through the high impact interventions (care bundle) approach, and there was a major emphasis on cleanliness and hygiene (particularly hand washing for clinical staff and environmental cleaning and disinfection in patient areas). Achievement of the target is not the end of the road; it is to be transformed into an objective (benchmark) for 2011 and beyond based on median rates to maintain pressure for reduction.

Is the war being won?--An expert's view.

With new DH guidance on dealing effectively with Clostridium difficile in healthcare settings recently published (see p40-43), Health Estate Journal spoke to Department of Health inspector of microbiology and infection control Professor Brian Duerden, asking him how much progress has been made in preventing outbreaks and containing spread, what lessons have been learned from some of the more high profile outbreaks, and what innovations, if any, are on the horizon to help eradicate the bacterium in future.

Controlling healthcare-associated infections in the NHS.

The prevention and control of healthcare-associated infection (HCAI) is a priority for the NHS. The delivery of national targets for reducing methicillin resistant Staphylococcus aureus bacteraemias and Clostridium difficile infection are supported by enhanced mandatory surveillance through the Health Protection Agency and a Department of Health improvement programme that promotes policies and protocols for enhancing clinical procedures and places infection prevention and control at the centre of clinical and corporate governance. The Health Act 2006 Code of Practice makes such policies and protocols a legal requirement and compliance will be assessed by the Healthcare Commission. Clinicians must recognise their responsibilities for patient safety and take a lead role in ensuring good practice to reduce HCAI.

Molecular investigation of genetic elements contributing to metronidazole resistance in Bacteroides strains.

OBJECTIVES: The aim of this study was to investigate the constitution of nim gene types, their activating insertion sequence (IS) element, their localization (plasmid or chromosome) and cfiA gene status in metronidazole-resistant Bacteroides strains (n=26) in order to examine their interchangeability. METHODS: Southern hybridization and conjugative plasmid transfer were used to localize the nimA-E genes and plasmid functions. PCR was used to detect the IS elements and the cfiA genes. PCR-mapping was applied to detect the nim gene-associated IS elements. PCR-mapping products and a nimE gene-containing plasmid fragment were sequenced. RESULTS: Nine of the nimA genes (12) were activated by IS1168 and nine were carried on plasmids, four of which were pIP417-like. The five nimB genes were chromosomal, and two of them were associated with IS1168 and one with IS612. Of the three nimC genes, two were activated by IS1170, and one was carried on a pIP419-like plasmid. The only nimD gene was chromosomal. The five nimE strains harboured the resistance genes on plasmids: one plasmid, pBF388c, 8.3 kb, was characterized, and a novel IS-like element was demonstrated upstream of all the nimE genes. The insertion events of some of these IS elements were restricted to certain nim gene-specific positions. The 11 chromosomal nim genes displayed a positive association with the cfiA gene-specific background. CONCLUSIONS: Fourteen strains harboured the well-known genetic elements: pIP417- and pIP419-like plasmids, chromosomal nimB genes and a common nimE plasmid. However, a rate of interchangeability was also demonstrated, mostly due to combinations of nim genes and their associated IS elements harboured on different replicons.

Twenty-first-century medical microbiology services in the UK.

With infection once again a high priority for the UK National Health Service (NHS), the medical microbiology and infection-control services require increased technology resources and more multidisciplinary staff. Clinical care and health protection need a coordinated network of microbiology services working to consistent standards, provided locally by NHS Trusts and supported by the regional expertise and national reference laboratories of the new Health Protection Agency. Here, I outline my thoughts on the need for these new resources and the ways in which clinical microbiology services in the UK can best meet the demands of the twenty-first century.

Extensive DNA inversions in the B. fragilis genome control variable gene expression.

The obligately anaerobic bacterium Bacteroides fragilis, an opportunistic pathogen and inhabitant of the normal human colonic microbiota, exhibits considerable within-strain phase and antigenic variation of surface components. The complete genome sequence has revealed an unusual breadth (in number and in effect) of DNA inversion events that potentially control expression of many different components, including surface and secreted components, regulatory molecules, and restriction-modification proteins. Invertible promoters of two different types (12 group 1 and 11 group 2) were identified. One group has inversion crossover (fix) sites similar to the hix sites of Salmonella typhimurium. There are also four independent intergenic shufflons that potentially alter the expression and function of varied genes. The composition of the 10 different polysaccharide biosynthesis gene clusters identified (7 with associated invertible promoters) suggests a mechanism of synthesis similar to the O-antigen capsules of Escherichia coli.

Actinomyces dentalis sp. nov., from a human dental abscess.

A previously undescribed filamentous, beaded, Gram-positive, rod-shaped bacterium was isolated from pus of a human dental abscess. Based on its cellular morphology and the results of biochemical testing the organism was tentatively identified as a member of the genus Actinomyces, but it did not correspond to any currently recognized species of this genus. Comparative 16S rRNA gene sequencing studies showed the bacterium represents a distinct subline within the genus Actinomyces, clustering within a group of species that includes Actinomyces bovis, the type species of the genus. Sequence divergence values of >8 % with other recognized species within this phylogenetic group clearly demonstrated that the organism represents a hitherto unknown species. Based on biochemical and molecular phylogenetic evidence, it is proposed that the unidentified organism recovered from a dental abscess be classified as a novel species, Actinomyces dentalis sp. nov. The type strain is R18165T (=CCUG 48064T=CIP 108337T).

Actinomyces nasicola sp. nov., isolated from a human nose.

A previously undescribed facultatively anaerobic, catalase-negative, Actinomyces-like bacterium was isolated from the nose of a human. On the basis of its cellular morphology and the results of biochemical testing, the micro-organism was tentatively identified as a member of the genus Actinomyces, but it did not correspond to any currently recognized species. Comparative 16S rRNA gene sequencing studies showed the bacterium to be a hitherto unknown subline within the genus Actinomyces, displaying sequence divergence values of more than 6 % with respect to recognized species of the genus. On the basis of biochemical, molecular chemical and molecular phylogenetic evidence, it is proposed that the unknown organism, strain R2014(T) (=CCUG 46092(T)=CIP 107668(T)), be classified as the type strain of a novel species, Actinomyces nasicola sp. nov.

Actinomyces oricola sp. nov., from a human dental abscess.

A previously undescribed Actinomyces-like bacterium was isolated from a human dental abscess. Based on its cellular morphology and the results of biochemical testing the organism was tentatively identified as a member of the genus Actinomyces, but it did not correspond to any currently recognized species of this genus. Comparative 16S rRNA gene sequencing studies showed the bacterium represents a hitherto unknown subline within the genus Actinomyces, clustering within a group of species, which includes Actinomyces bovis, the type species of the genus. Based on biochemical and molecular phylogenetic evidence, it is proposed that the unknown organism recovered from a dental abscess be classified as a new species, Actinomyces oricola sp. nov. The type strain of Actinomyces oricola is R5292(T) (=CCUG 46090(T)=CIP 107639(T)).

Corynebacterium atypicum sp. nov., from a human clinical source, does not contain corynomycolic acids.

An unusual gram-positive, facultatively anaerobic, catalase-positive, diphtheroid-shaped organism originating from an unknown human clinical source was characterized by biochemical, molecular chemical and molecular phylogenetic methods. Based on its morphological and biochemical characteristics and the presence of a murein based on meso-diaminopimelic acid, the unidentified organism was tentatively assigned to the genus Corynebacterium. However, the unknown organism was found to lack the distinctive, short-chain corynomycolic acids that are considered to be characteristic of this genus. Despite the absence of these characteristic lipids, comparative 16S rRNA gene sequencing showed that the unknown bacterium was phylogenetically a member of the genus Corynebacterium and was distinct from all currently known species. Based on both phenotypic and 16S rRNA sequence considerations, it is proposed that the unknown organism be classified as a novel species, Corynebacterium atypicum sp. nov. The type strain of C. atypicum is strain R2070T (=CCUG 45804T=CIP 107431T).

Actinobaculum urinale sp. nov., from human urine.

A hitherto undescribed Actinomyces-like bacterium was isolated from human urine. Based on its biochemical characteristics, the unidentified bacterium did not correspond to any currently described Actinomyces species or related taxa. Comparative 16S rRNA gene sequencing showed that the unknown bacterium exhibits a specific phylogenetic association with the genus Actinobaculum, but a sequence divergence of > 5% from the two currently recognized members of this genus, Actinobaculum schaalii and Actinobaculum suis, demonstrates that it represents a distinct species. Based on both phenotypic and 16S rRNA gene sequence considerations, it is proposed that the unknown bacterium from urine should be classified as a novel species, Actinobaculum urinale sp. nov. The type strain of Actinobaculum urinale is CCUG 46093(T) (= CIP 107424(T)).

Actinomyces vaccimaxillae sp. nov., from the jaw of a cow.

A previously undescribed Actinomyces-like bacterium was isolated from a lesion in the jaw of a cow. Based on its cellular morphology and the results of biochemical testing, the organism was tentatively identified as a member of the genus Actinomyces. Comparative 16S rRNA gene sequencing studies showed that the bacterium represents a hitherto unknown species within the genus Actinomyces, and is related to a group of species that includes Actinomyces turicensis and its close relatives. It is proposed that the unknown organism be classified as Actinomyces vaccimaxillae sp. nov. (the type strain is CCUG 46091T =CIP 107423T).

Characterization of some actinomyces-like isolates from human clinical sources: description of Varibaculum cambriensis gen nov, sp nov.

Fifteen strains of an anaerobic, catalase-negative, gram-positive diphtheroid-shaped bacterium recovered from human sources were characterized by phenotypic and molecular chemical and molecular genetic methods. The unidentified bacterium showed some resemblance to Actinomyces species and related taxa, but biochemical testing, polyacrylamide gel electrophoresis analysis of whole-cell proteins, and amplified 16S ribosomal DNA restriction analysis indicated the strains were distinct from all currently named Actinomyces species and related taxa. Comparative 16S rRNA gene sequencing studies showed that the bacterium represents a hitherto-unknown phylogenetic line that is related to but distinct from Actinomyces, Actinobaculum, Arcanobacterium, and Mobiluncus: We propose, on the basis of phenotypic and phylogenetic evidence, that the unknown bacterium from human clinical specimens should be classified as a new genus and species, Varibaculum cambriensis gen. nov., sp. nov. The type strain of Varibaculum cambriensis sp. nov. is CCUG 44998(T) = CIP 107344(T).

Actinomyces cardiffensis sp. nov. from human clinical sources.

Eight strains of a previously undescribed catalase-negative Actinomyces-like bacterium were recovered from human clinical specimens. The morphological and biochemical characteristics of the isolates were consistent with their assignment to the genus Actinomyces, but they did not appear to correspond to any recognized species. 16S rRNA gene sequence analysis showed the organisms represent a hitherto unknown species within the genus Actinomyces related to, albeit distinct from, a group of species which includes Actinomyces turicensis and close relatives. Based on biochemical and molecular genetic evidence, it is proposed that the unknown isolates from human clinical sources be classified as a new species, Actinomyces cardiffensis sp. nov. The type strain of Actinomyces cardiffensis is CCUG 44997(T).

Comparison of toxinotyping and PCR ribotyping of Clostridium difficile strains and description of novel toxinotypes.

Toxinotyping and PCR ribotyping are two methods that have been used to type Clostridium difficile isolates. Toxinotyping is based on PCR-RFLP analysis of a 19 kb region encompassing the C. difficile pathogenicity locus. PCR ribotyping is based on comparison of patterns of PCR products of the 16S-23S rRNA intergenic spacer region. Representative strains (101) from a C. difficile PCR ribotype library and 22 strains from previously described toxinotypes were analysed to compare ribotyping with toxinotyping. Within this panel of strains all 11 toxinotypes (0-X) described previously and an additional 5 novel toxinotypes (XI-XV) were observed. PCR ribotyping and toxinotyping correlated well and usually all strains within a given ribotype had similar changes in toxin genes. The new toxinotype XI comprises strains that did not express toxins TcdA or TcdB at detectable levels, but contained part of the tcdA gene. Strains of toxinotype XII exhibit changes only in the 5' end of the tcdB gene. Toxinotype XIV is composed of strains that have a large insertion at the beginning of the tcdA gene. A total of 25 of the 89 tested PCR ribotypes of C. difficile contained variant strains. It was estimated that they represent 7.7% of the total number of strains in the Anaerobe Reference Unit collection.

PCR ribotyping of clinically important Clostridium difficile strains from Hungary.

Isolates of Clostridium difficile from different hospital wards at the University Hospital of Szeged in Hungary were typed by PCR amplification of rRNA intergenic spacer regions (PCR ribotyping). A total of 15 different ribotypes was detected among the 65 isolates tested. The predominant type, PCR ribotype 087, accounted for 39% of all isolates, in contrast with an international typing study where ribotype 001 was the most common. Two non-toxigenic C. difficile strains were found to exhibit the same pattern, which was distinct from those of all the ribotypes described previously, suggesting that this is a new type.