Linoleic acid and α-linolenic acid inhibit conjugative transfer of an IncX4 plasmid carrying mcr-1.

AIMS: The aim of this study was to determine the effects of unsaturated fatty acids on clinical plasmids. METHODS AND RESULTS: Two unsaturated fatty acids, linoleic acid (LA) and α-linolenic acid (ALA) at final concentration 0, 0·03, 0·3 and 3 mmol l-1 , respectively, were used to assess the effects on conjugative transfer of a mcr-1-harbouring plasmid pCSZ4 (IncX4) in conjugation experiment. The inhibitory mechanisms were analysed by molecular docking and the gene expression of virB11 was quantitated by qRT-PCR. Target plasmid diversity was carried out by TrwD/VirB11 homology protein sequence prediction analysis. Our results showed that LA and ALA inhibit plasmid pCSZ4 transfer by binding to the amino acid residues (Phe124 and Thr125) of VirB11 with dose-dependent effects. The expression levels of virB11 gene were also significantly inhibited by LA and ALA treatment. Protein homology analysis revealed a wide distribution of TrwD/VirB11-like genes among over 37 classes of plasmids originated from both Gram-negative and Gram-positive bacteria. CONCLUSIONS: This study demonstrates representing a diversity of plasmids that may be potentially inhibited by unsaturated fatty acids. SIGNIFICANCE AND IMPACT OF THE STUDY: Our work reported here provides additional support for application of curbing the spread of multiple plasmids by unsaturated fatty acids.

Klebsiella pneumoniae ST307 with OXA-181: threat of a high-risk clone and promiscuous plasmid in a resource-constrained healthcare setting.

INTRODUCTION: Klebsiella pneumoniae with OXA-48-like enzymes were introduced into Tshwane Tertiary Hospital (TTH) (Pretoria, South Africa) during September 2015, causing nosocomial outbreaks. METHODS: PCR methodologies and WGS were used to characterize K. pneumoniae with carbapenemases (n = 124) from TTH (July 2015-December 2016). RESULTS: PCR was used to track K. pneumoniae ST307 with OXA-181 among 60% of carbapenemase-positive isolates in different wards/units over time and showed the transmission of IncX3 plasmids to other K. pneumoniae clones. WGS identified different ST307 clades: 307_OXA181 (consisting of two lineages, A and B) with OXA-181 on IncX3 plasmids (named p72_X3_OXA181) and clade 307_VIM with VIM-1 on IncFII plasmids. Clade 307_OXA181 lineage B was responsible for the rapid increase and transmission of OXA-181 K. pneumoniae in various wards/units throughout TTH, while the numbers of clade 307_OXA181 lineage A and clade 307_VIM remained low. Separate outbreaks were due to K. pneumoniae ST17 and ST29 with p72_X3_OXA181 plasmids. CONCLUSIONS: The high-risk clone K. pneumoniae ST307 with OXA-181 rapidly spread to different wards/units despite infection and prevention measures. ST307 clades and lineages seemingly acted differently in outbreak situations. This study also highlighted the threat of promiscuous plasmids such as p72_X3_OXA181.

Exploring genotype concordance in epidemiologically linked cases of tuberculosis in New York City.

Comparing genotype results of tuberculosis (TB) isolates from individuals diagnosed with TB can support or refute transmission; however, these conclusions are based upon the criteria used to define a genotype match. We used a genotype-match definition which allowed for variation in IS6110 restriction fragment length polymorphism (RFLP) to support transmission between epidemiologically linked persons. Contacts of individuals with infectious TB (index cases) diagnosed in New York City from 1997 to 2003 who subsequently developed TB (contact cases) from 1997 to 2007 were identified. For each contact case and index case (case-pair), isolate genotypes (spoligotype and RFLP results) were evaluated. Isolates from case-pairs were classified as exact or non-exact genotype match. Genotypes from non-exact match case-pairs were reviewed at the genotyping laboratory to determine if the isolates met the near-genotype-match criteria (exactly matching spoligotype and similar RFLP banding patterns). Of 118 case-pairs identified, isolates from 83 (70%) had exactly matching genotypes and 14 (12%) had nearly matching genotypes (supporting transmission), while the remaining 21 (18%) case-pairs had discordant genotypes (refuting transmission). Using identical genotype-match criteria for isolates from case-pairs epidemiologically linked through contact investigation may lead to underestimation of transmission. TB programmes should consider the value of expanding genotype-match criteria to more accurately assess transmission between such cases.

Molecular Characterization by Using Next-Generation Sequencing of Plasmids Containing blaNDM-7 in Enterobacteriaceae from Calgary, Canada.

Enterobacteriaceae with blaNDM-7 are relatively uncommon and had previously been described in Europe, India, the United States, and Japan. This study describes the characteristics of Enterobacteriaceae (Klebsiella pneumoniae [n = 2], Escherichia coli [n = 2], Serratia marcescens [n = 1], and Enterobacter hormaechei [n = 1] isolates) with blaNDM-7 obtained from 4 patients from Calgary, Canada, from 2013 to 2014. The 46,161-bp IncX3 plasmids with blaNDM-7 are highly similar to other blaNDM-harboring IncX3 plasmids and, interestingly, showed identical structures within the different isolates. This finding may indicate horizontal transmission within our health region, or it may indicate contact with individuals from areas of endemicity within the hospital setting. Patients infected or colonized with bacteria containing blaNDM-7 IncX3 plasmids generate infection control challenges. Epidemiological and molecular studies are required to better understand the dynamics of transmission, the risk factors, and the reservoirs for bacteria harboring blaNDM-7. To the best of our knowledge, this is the first report of S. marcescens and E. hormaechei with blaNDM-7.

Epidemiology and molecular characterization of bacteremia due to carbapenem-resistant Klebsiella pneumoniae in transplant recipients.

We conducted a retrospective study of 17 transplant recipients with carbapenem-resistant Klebsiella pneumoniae bacteremia, and described epidemiology, clinical characteristics and strain genotypes. Eighty-eight percent (15/17) of patients were liver or intestinal transplant recipients. Outcomes were death due to septic shock (18%), cure (24%) and persistent (>7 days) or recurrent bacteremia (29% each). Thirty- and 90-day mortality was 18% and 47%, respectively. Patients who were cured received at least one active antimicrobial agent and underwent source control interventions. Forty-one percent (7/17) of patients had intra-abdominal infections; all except one developed persistent/recurrent bacteremia despite drainage. Two patients tolerated persistent bacteremia for >300 days. All patients except one were infected with sequence type 258 (ST258), K. pneumoniae carbapenemase (KPC)-2-producing strains harboring a mutant ompK35 porin gene; the exception was infected with an ST37, KPC-3-producing strain. Seventy-one percent (12/17) of patients were infected with ST258 ompK36 mutant strains. In two patients, persistent bacteremia was caused by two strains with different ompK36 genotypes. Three ompK36 mutations were associated with significantly higher carbapenem minimum inhibitory concentrations than wild-type ompK36. Pulse-field gel electrophoresis identified a single ST258 lineage; serial strains from individual patients were indistinguishable. In conclusion, KPC-K. pneumoniae bacteremia exhibited highly diverse clinical courses following transplantation, and was caused by clonal ST258 strains with different ompK36 genotypes.

Growth-inhibitory activity of natural and synthetic isothiocyanates against representative human microbial pathogens.

AIMS: The aim of this study was to test the growth inhibition activity of isothiocyanates (ITCs), defence compounds of plants, against common human microbial pathogens. METHODS AND RESULTS: In this study, we have tested the growth-inhibitory activity of a diverse collection of new and previously known representative ITCs of various structural classes against pathogenic bacteria, fungi and moulds by a serial dilution method. Generally, the compounds were more active against Gram-positive bacteria and fungi exhibiting species-specific bacteriostatic or bactericidal effect. The most active compounds inhibited the growth of both drug-susceptible and multi-drug-resistant (MDR) pathogens at micromolar concentrations. In the case of Mycobacterium tuberculosis, some compounds were more active against MDR, rather than against susceptible strains. The average antimicrobial activity for some of the new derivatives was significantly higher than that previously reported for the most active ITC compounds. The structure-activity relationship (SAR) established for various classes of ITC with Bacillus cereus (model organism for B. anthracis) followed a distinct pattern, thereby enabling prediction of new more efficient inhibitors. Remarkably, tested bacteria failed to develop resistance to ITC. While effectively inhibiting microbial growth, ITCs displayed moderate toxicity towards eukaryotic cells. CONCLUSIONS: High antimicrobial activity coupled with moderate toxicity grants further thorough studies of the ITC compounds aimed at elucidation of their cellular targets and inhibitory mechanism. SIGNIFICANCE AND IMPACT OF THE STUDY: This systematic study identified new ITC compounds highly active against common human microbial pathogens at the concentrations comparable with those for currently used antimicrobial drugs (e.g. rifampicin and fluconazole). Tested representative pathogens do not develop resistance to the inhibitors. These properties justify further evaluation of ITC compounds as potential antimicrobial agents for medicinal use and for industrial applications.

Epidemiology of tuberculosis among healthcare personnel in New York City.

BACKGROUND: We have updated the epidemiology of tuberculosis (TB) among healthcare personnel (HCP) in New York City (NYC), USA, during a period of declining TB burden.METHODS: Using routinely collected Health Department data for NYC TB cases from 2001 to 2014, we conducted a retrospective descriptive analysis. P values were calculated using Pearson's χ² or Fisher's exact test for categorical data; Wilcoxon rank-sum test was used to compare medians. We used the Cochran-Armitage test for trend and linear regression for trend analyses.RESULTS: HCP accounted for 6% of adults with TB throughout the study period and were more likely than other adults to be female (68% vs. 37%, P ≤ 0.0001), have extrapulmonary-only disease (31% vs. 23%, P ≤ 0.0001), have an isolate with multidrug resistance (4% vs. 2%, P = 0.0211), and report a previous history of latent TB infection (LTBI) (51% vs. 23%, P ≤ 0.0001). Compared to non-US-born HCP, US-born HCP were more likely to have HIV infection (18% vs. 8%, P = 0.0011) or a genotypically clustered isolate (67% vs. 37%, P ≤ 0.0001) and less likely to report history of prior LTBI (43% vs. 54%, P = 0.0128).CONCLUSIONS: Further research is needed to explore transmission and occupational risk among HCP. New approaches are needed to optimize completion of prophylaxis for HCP with LTBI.

Dual ß-Lactam Combinations Highly Active against Mycobacterium abscessus Complex In Vitro.

As a consequence of a growing population of immunocompromised individuals, including transplant recipients and cystic fibrosis patients, there has been a dramatic increase in chronic infections caused by Mycobacterium abscessus complex (MABC) strains that are usually recalcitrant to effective antibiotic therapy. The recent rise of macrolide resistance in MABC has further complicated this clinical dilemma, dramatizing the need for novel agents. The repurposing of current antibiotics is one rapid path from discovery to patient care. In this study, we have discovered that dual ß-lactams, and specifically the combination of ceftazidime with either ceftaroline or imipenem, are synergistic and have clinically relevant activities, with MIC50s of 0.25 (ceftaroline with 100 µg/ml ceftazidime) and 0.5 µg/ml (imipenem with 100 µg/ml ceftazidime) against clinical MABC isolates. Similar synergy was observed in time-kill studies against the M. abscessus ATCC 19977 strain using clinically achievable concentrations of either imipenem (4 µg/ml) or ceftaroline (2 µg/ml), as the addition of ceftazidime at concentrations of ≥50 µg/ml showed a persistent bactericidal effect over 5 days. Treatment of THP-1 human macrophages infected with three different M. abscessus clinical isolates supported the in vitro findings, as the combination of 100 µg/ml ceftazidime and 0.125 µg/ml ceftaroline or 100 µg/ml ceftazidime and 0.25 µg/ml imipenem dramatically reduced the CFU counts to near baseline levels of infection. This study's finding that there is synergy between certain ß-lactam combinations against M. abscessus infection provides optimism toward identifying an optimum dual ß-lactam treatment regimen.IMPORTANCE The emergence of chronic MABC infections among immunocompromised populations and their inherent and acquired resistance to effective antibiotic therapy have created clinical challenges in advancing patients for transplant surgery and treating those with disease. There is an urgent need for new treatment regimens, and the repurposing of existing antibiotics provides a rapid strategy to advance a laboratory finding to patient care. Our recent discoveries that dual ß-lactams, specifically the combination of ceftazidime with ceftaroline or ceftazidime with imipenem, have significant in vitro MIC values and kill curve activities and are effective against infected THP-1 human macrophages provide optimism for a dual ß-lactam treatment strategy against MABC infections. The unexpected synergistic activities reported in this study create a new path of discovery to repurpose the large family of ß-lactam drugs.

An outbreak of methicillin-resistant Staphylococcus aureus skin infections resulting from horse to human transmission in a veterinary hospital.

There are increasing reports of methicillin-resistant Staphylococcus aureus (MRSA) infection and colonization in horses and evidence that MRSA can be transmitted between horses and humans. The objective of this study was to investigate reports of skin infection in personnel working with a foal with community-associated MRSA colonization and subsequent infection. Clinical diagnostic specimens were collected from individuals reporting skin lesions following contact with the affected foal. Nasal and groin screening swabs were collected from other veterinary personnel that attended a voluntary screening clinic. MRSA skin infections were identified in three neonatal intensive care unit personnel. Nasal colonization was subsequently identified in 10/103 (9.7%) other veterinary hospital personnel. Isolates were indistinguishable by pulsed field gel electrophoresis, classified as Canadian epidemic MRSA-5, possessed SCCmecIV, were negative for the Panton-Valentine leukocidin and were multidrug resistant. Transmission to veterinary personnel despite short-term contact with standard protective barriers highlights the potential importance of MRSA as an emerging zoonotic pathogen, and indicates that further evaluation of interspecies transmission of MRSA and means to prevent zoonotic infection are required.

Suspected transmission of methicillin-resistant Staphylococcus aureus between domestic pets and humans in veterinary clinics and in the household.

OBJECTIVE: To describe MRSA infection and colonization in household pets, and transmission of MRSA between animals and humans. METHODS: MRSA infection and colonization in household pets and human contacts were evaluated during investigations initiated after identification of MRSA infection or colonization of a household pet in order to determine if there had been transmission between animals and humans. All MRSA isolates were screened for Panton-Valentine leukocidin (PVL) genes by use of polymerase chain reaction, and isolate relatedness was determined by use of pulsed-field gel electrophoresis (PFGE). RESULTS: Investigations of six situations where MRSA was identified in one or more animals in a household or veterinary facility were performed. MRSA was isolated from 8 animals (5 dogs and 3 cats) with clinical infections, 1 cat that was in contact with 2 infected cats and 14/88 (16%) of household contacts or veterinary personnel. Both animal-to-human and human-to-animal transmission were suspected. An indistinguishable MRSA isolate was recovered from at least one human that was in contact with each animal case. All isolates were classified as Canadian epidemic MRSA-2, the predominant community-associated MRSA clone in humans in Canada. No isolates possessed genes encoding for the PVL. CONCLUSIONS: Transmission of MRSA between humans and animals, in both directions, was suspected. MRSA appears to be an emerging veterinary and zoonotic pathogen.

[Analysis of chromosome deletions of TbDl, RD6 and pks15/1 in clinical strains of Mycobacterium tuberculosis].

Deletions are very important sources of the variability among members of the mycobacterial tuberculosis complex (MTC). Deletion analysis of MTC clinical isolates was performed to clarify phylogenetic relationships and help to identify epidemiologically significant groups of the MTC. In this study, the variability of the TbDl, RD6 and pks15/1 chromosome loci in clinical MTC strains and comparison of those results with IS6110-RFLP (restriction fragment length polymorphism), sSNP (synonymous single nucleotide polymorphism), PGG (Principal Genetic Group) typing data were used to determine if these chromosome regions constitute good molecular markers for some of the epidemiologically important groups of the MTC. In the present study, 122, 61 and 294 clinical isolates were tested for the TbDl, RD6 and pks15/1 deletions, respectively. Specific probes were designed and used in RFLP analysis as well as sequencing techniques were applied. We found that all strains with intact TbDl region belonged to the sSNP cluster I, PGG 1 (katG463Leu and gyrA95Thr). The RD6 deletion was not determined to be a strict characteristic feature of any specific genetic group of the tested M.tb strains, but presence of this deletion is presumed for strains of high virulence, and associated with principal genetic groups 2 or 3. The genetic event that led to this deletion likely occurred in the strain that belongs to PGG 1. Identification of strains with an intact pksl5/1 gene cluster provided a potential marker for virulence. An intact pks15/1 gene cluster is required for the biosynthesis of the phenolic glycolipids (PGL-tb), production of which by clinical isolates was correlated with virulence.

Transmission trends for human immunodeficiency virus associated tuberculosis in New York City.

SETTING: Since 1992, tuberculosis (TB) control measures have reduced incidence rates in New York City and elsewhere. Nevertheless, trends have not been uniform in all demographic groups. OBJECTIVE: To characterize the epidemiology of human immunodeficiency virus (HIV) associated TB in New York during the 1990s, we analyzed social, demographic and clinical characteristics and genetic data on Mycobacterium tuberculosis isolates among persons with known HIV-status. DESIGN: A retrospective case-control study to compare patients with HIV-associated TB and patients with TB alone. RESULTS: Of 546 patients (70.5%) in the Department of Health Tuberculosis Control Registry treated for TB, 385 also had documented HIV status; 198 were HIV-infected (51%) and 187 (49%) were not. Genotype analysis of the 385 M. tuberculosis isolates identified 200 (52%) clustered strains, representing recent transmission. Although the overall percentage of TB cases associated with restriction fragment length polymorphism (RFLP) clustering fell over the period studied, HIV-associated cases were still much more likely to be associated with clustering than non-HIV-associated cases. CONCLUSIONS: Continued attention is required to contain the spread of TB in this vulnerable population.

A continuing survey of drug-resistant tuberculosis, New York City, April 1994.

BACKGROUND: A 1991 survey showed high levels of drug resistance among tuberculosis patients in New York, NY. As a result, the tuberculosis control program was strengthened, including expanded use of directly observed therapy and improved infection control. METHODS: We collected isolates from every patient in New York City with a positive culture for Mycobacterium tuberculosis during April 1994; results were compared with those in the April 1991 survey. RESULTS: From 1991 to 1994, the number of patients decreased from 466 to 332 patients. The percentage with isolates resistant to 1 or more antituberculosis drugs decreased from 33% to 24% (P < .01); with isolates resistant to at least isoniazid decreased from 26% to 18% (P < .05); and with isolates resistant to both isoniazid and rifampin decreased from 19% to 13% (P < .05). The number of patients with isolates resistant to both isoniazid and rifampin decreased by more than 50%. Among never previously treated patients, the percentage with resistance to 1 or more drugs decreased from 22% in 1991 to 13% in 1994 (P < .05). The number of patients with consistently positive culture results for more than 4 months decreased from 130 to 44. A history of antituberculosis treatment was the strongest predictor of drug resistance (odds ratio = 3.1; P < .001). Human immunodeficiency virus infection was associated with drug resistance among patients who never had been treated for tuberculosis. CONCLUSIONS: Drug-resistant tuberculosis declined significantly in New York City from 1991 to 1994. Measures to control and prevent tuberculosis were associated with a 29% decrease in the proportion of drug resistance and a 52% decrease in the number of patients with multidrug-resistant tuberculosis.

Susceptibility to levofloxacin of Myocobacterium tuberculosis isolates from patients with HIV-related tuberculosis and characterization of a strain with levofloxacin monoresistance. Community Programs for Clinical Research on AIDS 019 and the AIDS Clinical Trials Group 222 Protocol Team.

OBJECTIVE: To characterize the susceptibility to levofloxacin of clinical isolates of Mycobacterium tuberculosis (MTB) obtained from patients with HIV-related tuberculosis and to characterize the molecular genetics of levofloxacin resistance. DESIGN AND METHODS: Isolates from culture-positive patients in a United States multicenter trial of HIV-related TB were tested for susceptibility to levofloxacin by minimum inhibitory concentration (MIC) determinations in Bactec 7H12 broth. Automated sequencing of the resistance determining region of gyrA was performed. RESULTS: Of the 135 baseline MTB isolates tested, 134 (99%; 95% exact binomial confidence interval, 95.9-99.9%) were susceptible to levofloxacin with an MIC < or = 1.0 microg/ml. We identified a previously unrecognized mis-sense mutation occurring at codon 88 of gyrA in a levofloxacin mono-resistant MTB isolate obtained from a patient with AIDS who had received ofloxacin for 8 months prior to the diagnosis of tuberculosis. CONCLUSIONS: Clinical MTB isolates from HIV-infected patients were generally susceptible to levofloxacin. However, the identification of a clinical isolate with mono-resistance to levofloxacin highlights the need for circumspection in the use of fluoroquinolones in the setting of potential HIV-related tuberculosis and for monitoring of rates of resistance of MTB isolates to fluoroquinolones.

DNA fingerprints from Mycobacterium tuberculosis isolates of patients confined for therapy noncompliance show frequent clustering.

STUDY OBJECTIVE: To test the hypothesis that individuals chronically noncompliant with antituberculous chemotherapy are vectors for ongoing transmission of the disease in the community. DESIGN: Cohort study. SETTING: A large public hospital with a tuberculosis detention unit for patients with repeated and prolonged nonadherence to therapy. PATIENTS: Mycobacterium tuberculosis isolates from patients confined on the detention unit were obtained from the hospital's mycobacteriology laboratory. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: A standardized IS6110-based Southern blot hybridization protocol was used to genotype M tuberculosis isolates recovered from patients confined on the detention unit at the hospital. Each DNA fingerprint pattern was compared with the IS6110-fingerprint database at the Public Health Research Institute Tuberculosis Center, which has archived fingerprint patterns from over 2,500 M tuberculosis isolates collected from New York City patients in the past 5 years. Eighty percent of available isolates from detained patients belonged to an identifiable DNA fingerprint cluster, suggesting an epidemiologic link between the detainees and other New York City tuberculosis patients. CONCLUSIONS: Chronic noncompliance with therapy is associated with ongoing spread of tuberculosis in the community. Aggressive measures, including detention, for the small number of recalcitrant, noncompliant patients may interrupt a chain of transmission and contribute to a decline in the spread of tuberculosis in urban areas.

Multiple methicillin-resistant Staphylococcus aureus strains as a cause for a single outbreak of severe disease in hospitalized neonates.

Methicillin-resistant Staphylococcus aureus (MRSA) is an important cause of nosocomial infection. Outbreaks of infection caused by these pathogens are generally considered to be traceable to introduction of single strains into a hospital population. A large outbreak of bacteremic disease that recently occurred in our neonatal intensive care unit (11 episodes in 10 patients) involved 9 low birth weight infants and was associated with serious infection (4 episodes of meningitis). To determine the role of a single point source in this outbreak, isolates were characterized based on phenotypic and genotypic analyses. Phenotypic analysis included assessing hemolytic activity, phage typing, antimicrobial susceptibility testing and methicillin resistance population analysis. Genotypic analysis included assessment of plasmid profiles, dot-blot hybridization, restriction enzyme fragment pattern analysis and hybridization analysis of chromosomal DNA using a panel of staphylococcal gene probes. This analysis established that at least two distinct strains of MRSA were responsible for disease during this outbreak. This experience demonstrates the potential for MRSA to cause severe disease in the neonatal intensive care unit and indicates that the epidemiology of MRSA outbreaks is more complex than the spread of a single strain of bacteria.

Cross-contamination with Mycobacterium tuberculosis: an epidemiological and laboratory investigation.

OBJECTIVE: To investigate possible cross-contamination of laboratory specimens, as suggested by an increased incidence of newly diagnosed patients with tuberculosis, many of whom had all negative smears for acid-fast bacilli and only one positive Mycobacterium tuberculosis culture referred to as "negative smears, one positive" or NSOP. METHODS: Medical-record reviews were performed for all patients with NSOP results diagnosed at this facility within a 9-month period. Laboratory logbooks were reviewed for all isolates processed; DNA fingerprinting was performed on available isolates. RESULTS: Of 80 patients with NSOP results, 45 (56%) were found to have false-positive cultures resulting from laboratory contamination with H37Ra, an avirulent stock strain of Mycobacterium tuberculosis. CONCLUSION: Laboratory cross-contamination resulted in the false diagnosis of tuberculosis in at least 45 individuals. Use of the Mycobacteria Growth Indicator Tube may have contributed to these contamination incidents by detecting small numbers of contaminating mycobacteria that may not have been detected with less sensitive media.

Nosocomial transmission of a drug-sensitive W-variant Mycobacterium tuberculosis strain among patients with acquired immunodeficiency syndrome in Tennessee.

OBJECTIVE: To use DNA fingerprinting to characterize nosocomial spread of Mycobacterium tuberculosis following hospitalization of a patient with acquired immunodeficiency syndrome and active pulmonary tuberculosis, for whom respiratory isolation was not initiated promptly. DESIGN: Epidemiological investigation. SETTING: A tertiary-care medical center in Tennessee. PARTICIPANTS: Patients and healthcare workers potentially exposed to the infectious patient in 1992. RESULTS: Of 172 healthcare workers exposed, 35 (20%) were judged to have acquired tuberculous infection. Risk of acquisition was greatest for nurses and medical receptionists. Active tuberculosis later developed in one healthcare worker and one hospitalized patient. Nosocomial transmission was supported by epidemiological evidence and DNA fingerprinting. The outbreak strain of Mycobacterium tuberculosis differed from other isolates at this hospital, but its DNA hybridization pattern was highly similar to that of the multidrug-resistant outbreak strain W that has been prevalent in New York City, suggesting a common strain ancestry. However, the Tennessee isolates were susceptible to all first-line antituberculous agents. CONCLUSIONS: This report suggests the possibility that a molecular characteristic(s) shared by these successful outbreak strains is associated with increased transmissibility or pathogenicity and emphasizes the need for continued vigilance for tuberculosis in the nosocomial setting.

Mycobacterium tuberculosis specimen contamination revisited: the role of laboratory environmental control in a pseudo-outbreak.

OBJECTIVE: To investigate suspected pseudo-outbreaks of Mycobacterium tuberculosis (MTB) during August 1994 and July 1995 among patients who did not have clinical findings consistent with tuberculosis. DESIGN: Retrospective and prospective surveys of all clinical and laboratory data using standard epidemiological tools and DNA fingerprinting. SETTING: A university-affiliated community hospital. PATIENTS: Those with positive MTB cultures during periods when we noted that the number of MTB positive cultures greatly outnumbered the usual monthly average (retrospective analysis, 1994) and patients with positive MTB cultures without clinical findings consistent with tuberculosis (prospective survey, 1995). RESULTS: Epidemiological and molecular studies revealed specimen cross-contamination in the laboratory due to a faulty exhaust hood. Improvement in laboratory ventilation and change of the implicated hood prevented further specimen contamination. CONCLUSIONS: The identification of positive MTB cultures from patients without clinical evidence of tuberculosis should be a signal to suspect laboratory contamination and implement control measures. These should include a thorough epidemiological investigation, DNA fingerprint analysis, and an environmental inspection.

Testing the efficacy of a molecular surveillance network: methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus faecium (VREF) genotypes in six hospitals in the metropolitan New York City area. The BARG Initiative Pilot Study Group. Bacterial Antibiotic Resistance Group.

Molecular fingerprinting techniques are rapidly becoming indispensable tools for hospital epidemiology. On the other hand, the relative complexity and unfamiliarity of these techniques to most hospital diagnostic laboratories limit their usefulness. In an attempt to provide a solution for this dilemma, we tested the feasibility and efficacy of a cooperative venture in which molecular typing of isolates recovered from patients in six hospitals was performed at two microbiology research laboratories with expertise in these techniques. In a small preliminary study, 30 methicillin-resistant Staphylococcus aureus (MRSA) and 30 vancomycin-resistant Enterococcus faecium (VREF) isolates were collected over a 3-week period from six hospitals in the metropolitan New York area and transported to the Laboratory of Microbiology at The Rockefeller University during the summer months of 1994. Nineteen of the 27 confirmed MRSA isolates were closely related strains carrying the same mecA and the same Tn554 polymorphs in a pulsed-field gel electrophoresis (PFGE) background represented by closely related subtypes of a single pattern, indicating the wide distribution of this MRSA clone among the participating hospitals. Typing of the same 27 MRSA isolates was also performed at the Tuberculosis Center of the Public Health Research Institute and identical results were obtained. The 29 confirmed VREF isolates were highly heterogeneous and belonged to as many as 23 distinct clonal types as defined by PFGE patterns and probing with vanA. Characterization of the 60 isolates by these methods was completed in one month of full-time effort by a single experienced laboratory assistant guided by a doctoral-level expert in molecular fingerprinting techniques. The collection of samples for both MRSA and VREF was not intended to address epidemiological questions but to determine the feasibility of a multicenter study. On the basis of our preliminary findings we are encouraged that a larger cooperative effort is possible and with the correct sampling method we believe that epidemiological and surveillance studies could be accomplished that would provide a tracking system to assist hospitals, clinics, and chronic care facilities in controlling the spread of multidrug-resistant pathogens.