COVID-19: A Qualitative Analysis of Academic Family Physician Leaders' Crisis Response.

BACKGROUND AND OBJECTIVES: The onset of the COVID-19 pandemic severely threatened all aspects of academic family medicine, constituting a crisis. Multiple publications have identified recommendations and documented the creative responses of primary care and academic organizations to address these challenges, but there is little research on how decisions came about. Our objective was to gain insight into the context, process, and nature of family medicine leaders' discussions in pivoting to address a crisis. METHODS: We used a qualitative descriptive design to explore new dimensions of existing concepts. The setting was the academic family medicine department at the University of Toronto. To identify leadership themes, we used the constant comparative method to analyze transcripts of monthly meetings of the departmental executive: three meetings immediately before and three following the declaration of a state emergency in Ontario. RESULTS: Six themes were evident before and after the onset of the pandemic: building capacity in academic family medicine; developing leadership; advancing equity, diversity, and inclusion; learner safety and wellness; striving for excellence; and promoting a supportive and collegial environment. Five themes emerged as specific responses to the crisis: situational awareness; increased multidirectional communication; emotional awareness; innovation in education and patient care; and proactive planning for extended adaptation to the pandemic. CONCLUSION: Existing cultural and organizational approaches formed the foundation for the crisis response, while crisis-specific themes reflected skills and attitudes that are essential in clinical family medicine, including adapting to community needs, communication, and emotional awareness.

Specifying a relationship between semantic and episodic memory in the computation of a feature-based familiarity signal using MINERVA 2.

Approaches to modeling episodic recognition memory often imply a separability from semantic memory insofar as an implicit tabula rasa (i.e., blank slate) assumption is apparent in many simulations. This is evident in the common practice of having new test probes correspond to zero memory traces in the store while old test probes correspond to traces representing instances of items' occurrence on a study list. However, in list-learning studies involving word lists, none of the test items would actually correspond to zero items in the person's memory, as all of the test words are generally known to participants, whether old or new. By focusing on a list-learning recognition phenomenon that likely results from feature-based familiarity detection and necessarily involves a role of preexisting knowledge in its mechanisms-the semantic-feature-based recognition without cued recall phenomenon-we show how incorporating preexisting knowledge into the MINERVA 2 model enables it to simulate previously shown empirical patterns with this phenomenon. The simulation patterns reported here raise new theoretical implications worth further exploration, such as the extent to which the variances change in the signal versus the noise distribution when preexisting knowledge is present versus absent in the simulations.

Is glycemia control in Canadians with diabetes individualized? A cross-sectional observational study.

OBJECTIVE: Diabetes guidelines recommend individualized glycemic targets: tighter control in younger, healthier patients and consideration of more moderate control in the elderly and those with coexisting illnesses. Our objective was to examine whether glycemic control varied by age and comorbidities in Canadian primary care. RESEARCH DESIGN AND METHODS: Cross-sectional study using data from the electronic medical records of 537 primary care providers across Canada; 30 416 patients with diabetes, aged 40 or above, with at least one encounter and one hemoglobin A1c (HbA1c) measurement between 1 January 2012 and 31 December 2013. The outcome was the most recent HbA1c, categorized into three levels of control: tight (<7.0% or <53 mmol/mol), moderate (7.0%-8.5%, 53 mmol/mol-69.5 mmol/mol) and uncontrolled (>8.5% or >69.5 mmol/mol). We adjusted for several factors associated with glycemic control including treatment intensity. RESULTS: Younger patients (aged 40-49) were more likely to have moderate as opposed to tight control than the older patients (aged 80+) (OR 1.28; 95% CI 1.11 to 1.49, p=0.001). The youngest were also more likely to have uncontrolled as opposed to moderately controlled glycemia (OR 3.39; 95% CI 2.75 to 4.17, p<0.0001). Patients with no or only one comorbidity were more likely to have moderate as opposed to tight control than those with three or more comorbidities (OR 1.66;95% CI 1.46 to 1.90, p<0.0001). CONCLUSIONS: Levels of glycemic control, given age and comorbidities appear to differ from guideline recommendations. Research is needed to understand these discrepancies and develop methods to assist providers in personalizing glycemic targets.

Diversity of Antimicrobial Resistance Phenotypes in Salmonella Isolated from Commercial Poultry Farms.

Salmonella remains the leading cause of foodborne illness in the United States, and the dissemination of drug-resistant Salmonellae through the food chain has important implications for treatment failure of salmonellosis. We investigated the ecology of Salmonella in integrated broiler production in order to understand the flow of antibiotic susceptible and resistant strains within this system. Data were analyzed from a retrospective study focused on antimicrobial resistant Salmonella recovered from commercial broiler chicken farms conducted during the initial years of the US FDA's foray into retail meat surveillance by the National Antimicrobial Resistance Monitoring System (NARMS). Sixty-three percentage of Salmonella were pan-susceptible to a panel of 19 antimicrobials used by the NARMS program. Twenty-five antimicrobial resistance phenotypes were observed in Salmonella isolated from two broiler chicken farms. However, Salmonella displaying resistance to streptomycin, alone, and in combination with other antibiotics was the most prevalent (36.3%) antimicrobial resistance phenotype observed. Resistance to streptomycin and sulfadimethoxine appeared to be linked to the transposon, Tn21. Combinations of resistance against streptomycin, gentamicin, sulfadimethoxine, trimethoprim, and tetracycline were observed for a variety of Salmonella enterica serovars and genetic types as defined by pulsed-field gel electrophoresis. There were within and between farm differences in the antibiotic susceptibilities of Salmonella and some of these differences were linked to specific serovars. However, farm differences were not linked to antibiotic usage. Analysis of the temporal and spatial distribution of the endemic Salmonella serovars on these farms suggests that preventing vertical transmission of antibiotic-resistant Salmonella would reduce carcass contamination with antibiotic-resistant Salmonella and subsequently human risk exposure.

Are We Asking Patients if They Smoke?: Missing Information on Tobacco Use in Canadian Electronic Medical Records.

INTRODUCTION: All adolescent and adult patients should be asked if they smoke. Data entered in electronic medical records offer new opportunities to study tobacco-related clinical activities. The purpose of this study is to examine the recording of tobacco use in Canadian electronic medical records. METHODS: Data were collected on September 30, 2013, and analyzed in 2014. Data on 249,223 patients that were aged ≥16 years as of September 30, 2013 and had at least one primary care encounter in the previous 2 years were included. The proportion of patients with information on tobacco use entered in a summative health profile was calculated. Associations between data gaps and patient or physician factors were examined. RESULTS: Information on tobacco use was available for 64.4% of patients. Physicians using an electronic medical record for ≥4 years were more likely to have data (AOR=4.57, 95% CI=1.84, 7.29, p<0.0001). Patients aged ≥30 years were more likely to have tobacco information present (AOR=2.92, 95% CI=2.82, 3.02, p<0.0001, for patients aged 30-59 compared to those aged <30 years), as were patients with any comorbidities (AOR=1.41, 95% CI=1.36, 1.45, p<0.0001, for patients with one or two comorbidities compared with none) or more visits. CONCLUSIONS: A third of Canadians in this sample lacked data on tobacco in their electronic medical record. Younger, healthier people were less likely to have information about their smoking status. Efforts to improve the recording of tobacco-related information in electronic medical records, especially for younger patients, are needed.

Molecular characterization of antibiotic resistant Salmonella Typhimurium and Salmonella Kentucky isolated from pre- and post-chill whole broilers carcasses.

There is conflicting data regarding whether commercial chilling has any effect on persistence of Salmonella serovars, including antibiotic resistant variants, on chicken carcasses. A total of 309 Salmonella Typhimurium and Salmonella Kentucky isolates recovered from pre- and post-chill whole broiler carcasses were characterized for genetic relatedness using Pulsed Field Gel Electrophoresis (PFGE) and for the presence of virulence factors (invA, pagC, spvC) by PCR and for aerobactin and colicin production by bioassays. A subset of these isolates (n = 218) displaying resistance to either sulfisoxazole and/or ceftiofur [S. Typhimurium (n = 66) and S. Kentucky (n = 152)] were further tested for the presence of associated antibiotic resistance elements (class-I integrons and blaCMY genes) by PCR. All 145 ceftiofur resistant S. Kentucky and S. Typhimurium isolates possessed blaCMY genes. Class-I integrons were only detected in 6.1% (n = 4/66) of sulfisoxazole resistant S. Typhimurium isolates. The PFGE analysis revealed the presence of genetically diverse populations within the recovered isolates but clusters were generally concordant with serotypes and antimicrobial resistance profiles. At a 100% pattern similarity index, thirty-six percent of the undistinguishable S. Typhimurium and 22% of the undistinguishable S. Kentucky isolates were recovered from the same chilling step. All isolates possessed the invA and pagC genes, but only 1.4%possessed spvC. Irrespective of the chilling step, there was a significant difference (P < 0.05) in the production of aerobactin and colicin between S. Typhimurium and S. Kentucky isolates. Taken together, these results indicate that chilling impacted the recovery of particular Salmonella clonal groups but had no effect on the presence of class-I integrons, blaCMY genes, and tested virulence factors.

Comparative genomics of 28 Salmonella enterica isolates: evidence for CRISPR-mediated adaptive sublineage evolution.

Despite extensive surveillance, food-borne Salmonella enterica infections continue to be a significant burden on public health systems worldwide. As the S. enterica species comprises sublineages that differ greatly in antigenic representation, virulence, and antimicrobial resistance phenotypes, a better understanding of the species' evolution is critical for the prediction and prevention of future outbreaks. The roles that virulence and resistance phenotype acquisition, exchange, and loss play in the evolution of S. enterica sublineages, which to a certain extent are represented by serotypes, remains mostly uncharacterized. Here, we compare 17 newly sequenced and phenotypically characterized nontyphoidal S. enterica strains to 11 previously sequenced S. enterica genomes to carry out the most comprehensive comparative analysis of this species so far. These phenotypic and genotypic data comparisons in the phylogenetic species context suggest that the evolution of known S. enterica sublineages is mediated mostly by two mechanisms, (i) the loss of coding sequences with known metabolic functions, which leads to functional reduction, and (ii) the acquisition of horizontally transferred phage and plasmid DNA, which provides virulence and resistance functions and leads to increasing specialization. Matches between S. enterica clustered regularly interspaced short palindromic repeats (CRISPR), part of a defense mechanism against invading plasmid and phage DNA, and plasmid and prophage regions suggest that CRISPR-mediated immunity could control short-term phenotype changes and mediate long-term sublineage evolution. CRISPR analysis could therefore be critical in assessing the evolutionary potential of S. enterica sublineages and aid in the prediction and prevention of future S. enterica outbreaks.

Antimicrobial resistance, virulence, and genotypic profile comparison of Campylobacter jejuni and Campylobacter coli isolated from humans and retail meats.

A total of 360 spatially and temporally related Campylobacter isolates, including 168 from clinical human cases (Campylobacter jejuni n = 148; Campylobacter coli n = 20) and 192 from retail meats (C. jejuni n = 114; C. coli n = 78), were analyzed for antimicrobial susceptibilities, virulence, and genotypic profiles. Ciprofloxacin-resistant C. jejuni was observed in 13.5% and 19% of the isolates from humans and retail chicken breasts, respectively. Antimicrobial resistance to ciprofloxacin and erythromycin was detected in C. coli isolates recovered from 29% and 16.6% of retail meats and 15% and 5% humans, respectively. Overall, virulence determinants were more prevalent in Campylobacter isolates recovered from retail meats than from humans. C. jejuni isolates from humans were significantly associated with the rakR, dnaJ, and pld genes, whereas C. coli isolates from retail meats were associated with the dnaJ, pld, and virB11 virulence genes. Genotyping of 262 C. jejuni isolates using pulsed-field gel electrophoresis revealed a total of 186 unique SmaI patterns, with 14% of patterns composed of isolates recovered from retail meats and ill humans. All unique groups with indistinguishable SmaI patterns were further analyzed by a second restriction enzyme (KpnI), which revealed limited overlap between isolates from different sources. Significant association between doxycycline-resistant C. jejuni strains recovered from humans and different virulence genes (e.g., cdtB) was identified at the statistical level but not at the genotypic level. In conclusion, significant differences observed in the distribution of antimicrobial resistance profiles, virulence determinants, and genotypic diversity among C. jejuni and C. coli isolates indicate that there are sources other than retail meats that may also contribute to human Campylobacter infections.

Evaluation of antimicrobial resistance phenotypes for predicting multidrug-resistant Salmonella recovered from retail meats and humans in the United States.

Although multidrug-resistant (MDR) non-Typhi Salmonella (NTS) strains are a concern in food production, determining resistance to multiple antimicrobial agents at slaughter or processing may be impractical. Single antimicrobial resistance results for predicting multidrug resistance are desirable. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value were used to determine each antimicrobial agent's ability to predict MDR phenotypes of human health significance: ACSSuT (resistance to at least ampicillin, chloramphenicol, streptomycin, sulfamethoxazole, tetracycline) in NTS isolates, and MDR-AmpC-SN (resistance to ACSSuT, additional resistance to amoxicillin-clavulanate and to ceftiofur, and decreased susceptibility [MIC >= 2 microg/ml] to ceftriaxone) in NTS serotype Newport. The U.S. National Antimicrobial Resistance Monitoring System determined MICs to 15 or more antimicrobial agents for 9,955 NTS isolates from humans from 1999 to 2004 and 689 NTS isolates from retail meat from 2002 to 2004. A total of 847 (8.5%) human and 26 (3.8%) retail NTS isolates were ACSSuT; 995 (10.0%) human and 16 (2.3%) retail isolates were serotype Newport. Among Salmonella Newport, 204 (20.5%) human and 9 (56.3%) retail isolates were MDR-AmpC-SN. Chloramphenicol resistance provided the highest PPVs for ACSSuT among human (90.5%; 95% confidence interval, 88.4 to 92.3) and retail NTS isolates (96.3%; 95% confidence interval, 81.0 to 99.9). Resistance to ceftiofur and to amoxicillin-clavulanate and decreased susceptibility to ceftriaxone provided the highest PPVs (97.1, 98.1, and 98.6%, respectively) for MDR-AmpC-SN from humans. High PPVs for these agents applied to retail meat MDR-AmpC-SN, but isolate numbers were lower. Variations in MIC results may complicate ceftriaxone's predictive utility. Selecting specific antimicrobial resistance offers practical alternatives for predicting MDR phenotypes. Chloramphenicol resistance works best for ACSSuT-NTS, and resistance to ceftiofur, amoxicillin-clavulanate, or chloramphenicol works best for MDR-AmpC-SN.

A prospective 1-year study of changes in neuropsychological functioning after implantable cardioverter-defibrillator surgery.

BACKGROUND: The testing of the implantable cardioverter-defibrillator (ICD), through the induction of repeated episodes of ventricular fibrillation, has been associated with disturbances in cerebral activity and increased levels of cytoplasmic enzymes. However, the neuropsychological outcomes of cerebral changes and their quality-of-life implications are unknown. METHODS AND RESULTS: Fifty-two ICD recipients completed standardized validated neuropsychological tests 1 to 3 days before ICD surgery and then 6 weeks, 6 months, and 12 months after surgery. They also completed psychometric tests measuring anxiety, depression, and quality of life. Between 31% and 39% of patients showed a significant neuropsychological impairment from their baseline function 6 weeks, 6 months, and 12 months after surgery. Ten percent of patients had late-onset deficits at 12 months only. Frequent areas of impairment were auditory and visual memory and attention. Neuropsychological impairment was not related to mood or quality of life at follow-up, although anxiety and depression predicted reduced quality of life. CONCLUSIONS: ICD implantation is associated with neuropsychological impairment that dissipates for the majority of recipients after 12 months. Short-term memory function and attention are particularly vulnerable to changes in oxygen during ICD testing. Although anxiety and depression are prevalent, there is little evidence for the direct impact of mood on cognition, and deficits appear not to be associated with reduced quality of life. These results provide evidence for longitudinal outcomes of ICD surgery and have implications for patient rehabilitation and adjustment.

Pre-ICD illness beliefs affect postimplant perceptions of control and patient quality of life.

BACKGROUND: The implantable cardioverter defibrillator (ICD) is a device used in the treatment of ventricular arrhythmias and the prevention of sudden cardiac death. However, the ICD has been associated with negative psychological outcomes such as anxiety, depression, panic, and poor quality of life (QoL). Recent studies suggest that the preimplantation psychology of patients, combined with their postimplantation perceptions about their cardiac condition, are greater contributory factors than their medical status to a poor outcome. METHOD: Our study employed an interview-based qualitative grounded theory methodology to explore whether medical history hetereogeneity and illness beliefs impact on the QoL of 13 ICD patients. RESULTS: Perceived control emerged as the core category related to QoL with three subsystem themes related to control: (1) illness beliefs, attributions, and appraisals; (2) coping resources and strategies; and (3) the social world. Patients at risk for the poorest adaptation were younger (<45), unemployed, and with an acute onset cardiac history. These patients interpreted their illness as severe, utilized emotion-focused coping (e.g., avoidance of situations), and believed themselves to be socially excluded. Adjusted patients used proactive problem-focused coping (e.g., normalizing) and minimized consequences of the device. CONCLUSIONS: The data developed a theoretical model of QoL, which identified perceived control, illness beliefs, and coping impacting on adjustment. From our study, we have a wider understanding of the combination psychological issues relevant to ICD patients and are able to treat those at risk with interventions to promote adjustment in the context of a society that values health and well-being.

Horizontal gene transfer of a ColV plasmid has resulted in a dominant avian clonal type of Salmonella enterica serovar Kentucky.

Salmonella enterica continues to be a significant cause of foodborne gastrointestinal illness in humans. A wide variety of Salmonella serovars have been isolated from production birds and from retail poultry meat. Recently, though, S. enterica subsp. enterica serovar Kentucky has emerged as one of the prominent Salmonella serovars isolated from broiler chickens. Recent work suggests that its emergence apparently coincides with its acquisition of a ColV virulence plasmid. In the present study, we examined 902 Salmonella isolates belonging to 59 different serovars for the presence of this plasmid. Of the serovars examined, the ColV plasmid was found only among isolates belonging to the serovars Kentucky (72.9%), Typhimurium (15.0%) and Heidelberg (1.7%). We demonstrated that a single PFGE clonal type of S. Kentucky harbors this plasmid, and acquisition of this plasmid by S. Kentucky significantly increased its ability to colonize the chicken cecum and cause extraintestinal disease. Comparison of the completed sequences of three ColV plasmids from S. Kentucky isolated from different geographical locales, timepoints and sources revealed a nearly identical genetic structure with few single nucleotide changes or insertions/deletions. Overall, it appears that the ColV plasmid was recently acquired by a single clonal type S. Kentucky and confers to its host enhanced colonization and fitness capabilities. Thus, the potential for horizontal gene transfer of virulence and fitness factors to Salmonella from other enteric bacteria exists in poultry, representing a potential human health hazard.

A rapid screen of broth enrichments for Salmonella enterica serovars enteritidis, Hadar, Heidelberg, and Typhimurium by Using an allelotyping multiplex PCR that targets O- and H-antigen alleles.

Salmonella continues to cause significant foodborne outbreaks, best illustrated with recent outbreaks associated with peanut butter, raw tomatoes, and serrano peppers. To ascertain the likely source of the outbreak, bacterial typing is essential to this process. While PCR has become an important detection tool for pathogens in foods, PCR can also identify strain differences by targeting gene(s) or sequences exhibiting polymorphisms or variability in its distribution within the bacterial population. Over 2,500 Salmonella enterica serovars identified based on antigenic differences in lipopolysaccharide and flagellin have been identified to date. We developed an allelotyping PCR scheme that identifies the O and H alleles associated with S. enterica serovars Enteritidis, Hadar, Heidelberg, Typhimurium, and others, with the same antigen alleles but in different O- and H-allele combinations (e.g., S. enterica Kentucky), and validated it as a screen to identify samples contaminated with these Salmonella serovars. We correctly identified poultry samples containing S. enterica serovars Enteritidis, Kentucky, and Typhimurium from our multiplex screen of primary enrichments of environmental drag swabs. PCR agreed well (kappa values = 0.81 to 1.0) with conventional serotyping methods used to type salmonellae isolated from primary enrichment. Coupled with Salmonella-specific PCR, such as invA, this allelotyping PCR could prove useful in the identification of Salmonella and specific S. enterica serovars present in foods or the environment and could decrease the time and cost associated with conventional serotyping methods.

Antimicrobial resistance-conferring plasmids with similarity to virulence plasmids from avian pathogenic Escherichia coli strains in Salmonella enterica serovar Kentucky isolates from poultry.

Salmonella enterica, a leading cause of food-borne gastroenteritis worldwide, may be found in any raw food of animal, vegetable, or fruit origin. Salmonella serovars differ in distribution, virulence, and host specificity. Salmonella enterica serovar Kentucky, though often found in the food supply, is less commonly isolated from ill humans. The multidrug-resistant isolate S. Kentucky CVM29188, isolated from a chicken breast sample in 2003, contains three plasmids (146,811 bp, 101,461 bp, and 46,121 bp), two of which carry resistance determinants (pCVM29188_146 [strAB and tetRA] and pCVM29188_101 [bla(CMY-2) and sugE]). Both resistance plasmids were transferable by conjugation, alone or in combination, to S. Kentucky, Salmonella enterica serovar Newport, and Escherichia coli recipients. pCVM29188_146 shares a highly conserved plasmid backbone of 106 kb (>90% nucleotide identity) with two virulence plasmids from avian pathogenic Escherichia coli strains (pAPEC-O1-ColBM and pAPEC-O2-ColV). Shared avian pathogenic E. coli (APEC) virulence factors include iutA iucABCD, sitABCD, etsABC, iss, and iroBCDEN. PCR analyses of recent (1997 to 2005) S. Kentucky isolates from food animal, retail meat, and human sources revealed that 172 (60%) contained similar APEC-like plasmid backbones. Notably, though rare in human- and cattle-derived isolates, this plasmid backbone was found at a high frequency (50 to 100%) among S. Kentucky isolates from chickens within the same time span. Ninety-four percent of the APEC-positive isolates showed resistance to tetracycline and streptomycin. Together, our findings of a resistance-conferring APEC virulence plasmid in a poultry-derived S. Kentucky isolate and of similar resistance/virulence plasmids in most recent S. Kentucky isolates from chickens and, to lesser degree, from humans and cattle highlight the need for additional research in order to examine the prevalence and spread of combined virulence and resistance plasmids in bacteria in agricultural, environmental, and clinical settings.

Examination of the source and extended virulence genotypes of Escherichia coli contaminating retail poultry meat.

Extraintestinal pathogenic Escherichia coli (ExPEC) are major players in human urinary tract infections, neonatal bacterial meningitis, and sepsis. Recently, it has been suggested that there might be a zoonotic component to these infections. To determine whether the E. coli contaminating retail poultry are possible extraintestinal pathogens, and to ascertain the source of these contaminants, they were assessed for their genetic similarities to E. coli incriminated in colibacillosis (avian pathogenic E. coli [APEC]), E. coli isolated from multiple locations of apparently healthy birds at slaughter, and human ExPEC. It was anticipated that the retail poultry isolates would most closely resemble avian fecal E. coli since only apparently healthy birds are slaughtered, and fecal contamination of carcasses is the presumed source of meat contamination. Surprisingly, this supposition proved incorrect, as the retail poultry isolates exhibited gene profiles more similar to APEC than to fecal isolates. These isolates contained a number of ExPEC-associated genes, including those associated with ColV virulence plasmids, and many belonged to the B2 phylogenetic group, known to be virulent in human hosts. Additionally, E. coli isolated from the crops and gizzards of apparently healthy birds at slaughter also contained a higher proportion of ExPEC-associated genes than did the avian fecal isolates examined. Such similarities suggest that the widely held beliefs about the sources of poultry contamination may need to be reassessed. Also, the presence of ExPEC-like clones on retail poultry meat means that we cannot yet rule out poultry as a source of ExPEC human disease.

Comparative genomics of the IncA/C multidrug resistance plasmid family.

Multidrug resistance (MDR) plasmids belonging to the IncA/C plasmid family are widely distributed among Salmonella and other enterobacterial isolates from agricultural sources and have, at least once, also been identified in a drug-resistant Yersinia pestis isolate (IP275) from Madagascar. Here, we present the complete plasmid sequences of the IncA/C reference plasmid pRA1 (143,963 bp), isolated in 1971 from the fish pathogen Aeromonas hydrophila, and of the cryptic IncA/C plasmid pRAx (49,763 bp), isolated from Escherichia coli transconjugant D7-3, which was obtained through pRA1 transfer in 1980. Using comparative sequence analysis of pRA1 and pRAx with recent members of the IncA/C plasmid family, we show that both plasmids provide novel insights into the evolution of the IncA/C MDR plasmid family and the minimal machinery necessary for stable IncA/C plasmid maintenance. Our results indicate that recent members of the IncA/C plasmid family evolved from a common ancestor, similar in composition to pRA1, through stepwise integration of horizontally acquired resistance gene arrays into a conserved plasmid backbone. Phylogenetic comparisons predict type IV secretion-like conjugative transfer operons encoded on the shared plasmid backbones to be closely related to a group of integrating conjugative elements, which use conjugative transfer for horizontal propagation but stably integrate into the host chromosome during vegetative growth. A hipAB toxin-antitoxin gene cluster found on pRA1, which in Escherichia coli is involved in the formation of persister cell subpopulations, suggests persistence as an early broad-spectrum antimicrobial resistance mechanism in the evolution of IncA/C resistance plasmids.

Molecular Analysis of Escherichia coli from retail meats (2002-2004) from the United States National Antimicrobial Resistance Monitoring System.

BACKGROUND: The origins and virulence potential of meat product-associated Escherichia coli are undefined. METHODS: Two hundred eighty-seven E. coli isolates (145 resistant and 142 susceptible to trimethoprim-sulfamethoxazole, nalidixic acid, and/or ceftiofur), recovered by the United States National Antimicrobial Monitoring System from retail beef, pork, chicken, and turkey products (from Oregon, Tennessee, Georgia, and Maryland, 2002-2004) underwent polymerase chain reaction testing for phylogenetic groupings and 59 virulence-associated genes. RESULTS: However analyzed, resistant and susceptible isolates differed minimally according to the assessed characteristics. In contrast, the 4 meat types differed greatly for multiple individual traits and aggregate virulence scores. Poultry isolates exhibited virulence genes associated with avian pathogenic E. coli; beef isolates exhibited traits associated with E. coli from diseased cattle. Overall, 20% of isolates qualified as extraintestinal pathogenic E. coli, with poultry isolates exhibiting significantly higher virulence scores than beef and pork isolates (P < .001). CONCLUSIONS: Within this systematically collected, geographically distributed sample of recent retail meat isolates, the carriage of extraintestinal pathogenic E. coli virulence genes in antimicrobial-resistant and antimicrobial-susceptible E. coli appeared similar, whereas isolates from different types of meat differed, consistent with on-farm acquisition of resistance within host species-specific E. coli populations. A substantial minority of meat-source E. coli (whether susceptible or resistant) may represent potential human pathogens.

Characterization of antimicrobial resistance in Salmonella enterica serotype Heidelberg isolated from food animals.

Fifty-eight Salmonella enterica serovar Heidelberg isolates isolated from food animals were tested for antimicrobial susceptibilities and further characterized for select antimicrobial resistance genes, plasmid carriage, class 1 integrons, and genetic relatedness using pulsed-field gel electrophoresis (PFGE). Seventy-two percent of isolates displayed resistance to at least one of the antimicrobial agents tested, while 24% exhibited resistance to eight or more antimicrobial agents. Resistance was most commonly observed to tetracycline (71%), streptomycin (62%), and kanamycin (52%). Isolates obtained from cattle and swine displayed the highest rates of resistance while isolates from chickens more often displayed susceptibility to the tested antimicrobials. When resistance was detected, a corresponding resistance gene was detected in 97.3% of the isolates. Thirteen percent of the isolates contained class 1 integrons containing at least one resistance gene, most often either the aadA or dhfrA genes, which are often associated with resistance to streptomycin and trimethoprim, respectively. Twenty isolates contained plasmids estimated to be at least 75 kb in size, 17 of which exhibited resistance to five or more antimicrobial agents. Thirty PFGE patterns were generated among the 58 isolates tested using XbaI, indicating extensive heterogeneity among this serotype across different animal origins. Results confirm the presence of multidrug-resistance (MDR) phenotypes among food animal isolates of serovar Heidelberg, especially those obtained from mammalian species. The observed MDR was typically associated with the presence of large plasmids.

Rapid screening of Salmonella enterica serovars Enteritidis, Hadar, Heidelberg and Typhimurium using a serologically-correlative allelotyping PCR targeting the O and H antigen alleles.

BACKGROUND: Classical Salmonella serotyping is an expensive and time consuming process that requires implementing a battery of O and H antisera to detect 2,541 different Salmonella enterica serovars. For these reasons, we developed a rapid multiplex polymerase chain reaction (PCR)-based typing scheme to screen for the prevalent S. enterica serovars Enteritidis, Hadar, Heidelberg, and Typhimurium. RESULTS: By analyzing the nucleotide sequences of the genes for O-antigen biosynthesis including wba operon and the central variable regions of the H1 and H2 flagellin genes in Salmonella, designated PCR primers for four multiplex PCR reactions were used to detect and differentiate Salmonella serogroups A/D1, B, C1, C2, or E1; H1 antigen types i, g, m, r or z10; and H2 antigen complexes, I: 1,2; 1,5; 1,6; 1,7 or II: e,n,x; e,n,z15. Through the detection of these antigen gene allele combinations, we were able to distinguish among S. enterica serovars Enteritidis, Hadar, Heidelberg, and Typhimurium. The assays were useful in identifying Salmonella with O and H antigen gene alleles representing 43 distinct serovars. While the H2 multiplex could discriminate between unrelated H2 antigens, the PCR could not discern differences within the antigen complexes, 1,2; 1,5; 1,6; 1,7 or e,n,x; e,n,z15, requiring a final confirmatory PCR test in the final serovar reporting of S. enterica. CONCLUSION: Multiplex PCR assays for detecting specific O and H antigen gene alleles can be a rapid and cost-effective alternative approach to classical serotyping for presumptive identification of S. enterica serovars Enteritidis, Hadar, Heidelberg, and Typhimurium.