Frequency of occurrence, seasonal variation and antifungal susceptibility of opportunistic Mucorales isolated from hospital soils in Iran.

BACKGROUND: Mucorales are opportunistic pathogens that can cause life-threatening diseases predominantly in immunocompromised patients. OBJECTIVES: This study aimed to investigate the frequency, seasonal variation and antifungal susceptibility of pathogenic Mucorales in the soil collected from seven hospitals in Urmia, Iran, between November 2017 and July 2018 in four different seasons. METHODS: Mucorales isolates obtained from soil were characterised based on conventional and molecular assays. In addition, in vitro antifungal susceptibility was performed using the CLSI M38Ed3 procedure. RESULTS: Out of 196 tested soil samples, 80 (40.8%) samples were positive for mucoralean fungi. Rhizopus arrhizus var. arrhizus (n = 47) was the most frequent species followed by Mucor circinelloides (n = 21) and Cunninghamella echinulata (n = 6). A seasonal variation in the frequency of Mucorales in soil was detected with a maximum of culture-positive soil samples detected in wet autumn (43.2%) followed by winter (23.4%), summer (19.7%) and spring (13.6%). In vitro antifungal susceptibility testing for 80 environmental isolates exhibited MIC of ≤2 µg/ml for amphotericin B indicating the smallest range of MIC variation among the tested Mucorales (range: 0.125-2 µg/ml). Among the azoles, posaconazole was the most effective antifungals (GM MIC, 0.724 µg/ml). CONCLUSIONS: We considered associations of species and seasonal frequencies between soil mucoralean fungi and mucormycosis. The effect of opportunistic Mucorales dominating in the soil and prevalent causative agents of mucormycosis in Iran reported in the literatures but more comprehensive studies are needed to confirm this conclusion.

Fungal infections in animals: a patchwork of different situations.

The importance of fungal infections in both human and animals has increased over the last decades. This article represents an overview of the different categories of fungal infections that can be encountered in animals originating from environmental sources without transmission to humans. In addition, the endemic infections with indirect transmission from the environment, the zoophilic fungal pathogens with near-direct transmission, the zoonotic fungi that can be directly transmitted from animals to humans, mycotoxicoses and antifungal resistance in animals will also be discussed. Opportunistic mycoses are responsible for a wide range of diseases from localized infections to fatal disseminated diseases, such as aspergillosis, mucormycosis, candidiasis, cryptococcosis and infections caused by melanized fungi. The amphibian fungal disease chytridiomycosis and the Bat White-nose syndrome are due to obligatory fungal pathogens. Zoonotic agents are naturally transmitted from vertebrate animals to humans and vice versa. The list of zoonotic fungal agents is limited but some species, like Microsporum canis and Sporothrix brasiliensis from cats, have a strong public health impact. Mycotoxins are defined as the chemicals of fungal origin being toxic for warm-blooded vertebrates. Intoxications by aflatoxins and ochratoxins represent a threat for both human and animal health. Resistance to antifungals can occur in different animal species that receive these drugs, although the true epidemiology of resistance in animals is unknown, and options to treat infections caused by resistant infections are limited.

Opportunistic Pulmonary Bordetella hinzii Infection after Avian Exposure.

We report 2 cases of pulmonary Bordetella hinzii infection in immunodeficient patients. One of these rare cases demonstrated the potential transmission of the bacteria from an avian reservoir through occupational exposure and its persistence in humans. We establish bacteriologic management of these infections and suggest therapeutic options if needed.

Background Paper for the update of meningococcal vaccination recommendations in Germany: use of the serogroup B vaccine in persons at increased risk for meningococcal disease.

In December 2013 Bexsero® became available in Germany for vaccination against serogroup B meningococci (MenB). In August 2015 the German Standing Committee on Vaccination (STIKO) endorsed a recommendation for use of this vaccine in persons at increased risk of invasive meningococcal disease (IMD). This background paper summarizes the evidence underlying the recommendation. Bexsero® is based on surface protein antigens expressed by about 80% of circulating serogroup B meningococci in Germany. The paper reviews available data on immunogenicity and safety of Bexsero® in healthy children and adolescents; data in persons with underlying illness and on the effectiveness in preventing clinical outcomes are thus far unavailable.STIKO recommends MenB vaccination for the following persons based on an individual risk assessment: (1) Persons with congenital or acquired immune deficiency or suppression. Among these, persons with terminal complement defects and properdin deficiency, including those under eculizumab therapy, are at highest risk with reported invasive meningococcal disease (IMD) incidences up 10,000-fold higher than in the general population. Persons with asplenia were estimated to have a ~ 20-30-fold increased risk of IMD, while the risk in individuals with other immune defects such as HIV infection or hypogammaglobulinaemia was estimated at no more than 5-10-fold higher than the background risk. (2) Laboratory staff with a risk of exposure to N. meningitidis aerosols, for whom an up to 271-fold increased risk for IMD has been reported. (3) Unvaccinated household (-like) contacts of a MenB IMD index case, who have a roughly 100-200-fold increased IMD risk in the year after the contact despite chemoprophylaxis. Because the risk is highest in the first 3 months and full protective immunity requires more than one dose (particularly in infants and toddlers), MenB vaccine should be administered as soon as possible following identification of the serogroup of the index case.

Subcutaneous (deep) fungal infections.

Fungal infection is a common clinical problem in dermatology. While most cases in practice are superficial infections, invasive subcutaneous mycoses are important to recognize and treat, as these conditions often have significant morbidity and mortality. Deep fungi demonstrate species-specific syndromes and may be identified by clinical and histological features in addition to serological evaluation and culture. Identification of the common innoculation subcutaneous mycoses, as well as those associated with pulmonary primary infection and dissemination to the skin is important, as treatments vary by organism and clinical setting. This overview will help to identify the key dermatological presentations of subcutaneous fungal infection, and the clues they give to cause.

[Protozoa and protozoan infections of humans in Central Europe]. / Protozoen und Protozoen-Infektionen des Menschen in Mitteleuropa.

This article is a condensed review of the medically relevant protozoa in Central Europe and the infections and diseases caused by them. Information is given on modes and sources of infection, organs involved in the disease, prevalence, diagnostics, therapy, and prophylaxis. Moreover, travel-associated infections with protozoa are briefly outlined.

Parasitoses with central nervous system involvement.

Most of the parasitoses manifest systemically, including the central nervous system (CNS). Among the most prevalent parasitoses in Central Europe (cysticercosis, toxocarosis, echinococcosis, and toxoplasmosis), cerebral involvement is well recognized and part of the clinical presentation, which cannot be neglected. CNS involvement results from invasion of larvae of these parasites via the blood stream or by direct migration into the CNS. Most frequently larvae reside within the cerebral parenchyma, but sometimes also within the ventricles, in the meningeas within cerebral aneurysms, or in the parenchyma of the spinal cord. Depending on the stage of their development, they cause a local defect or more widespread damage, such as encephalitis, ventriculitis, ependymitis, arachnoiditis, meningitis, myelitis, polyradiculitis, mechanical obstruction of the arterial or cerebrospinal fluid (CSF) flow, or vasculitis with appropriate clinical presentations. These include epilepsy, headache, impaired consciousness, orientation, cognition, focal neurological motor, sensory, or vegetative deficits, or visual impairment. CNS involvement is diagnosed on the clinical presentation, the epidemiological background, blood and CSF investigations, imaging studies, and sometimes biopsy. Treatment is based on various antihelminthic agents and, occasionally, surgery.

[Retrospective study of the implementation of the qualitative PCR technique in biological samples for monitoring toxoplasmosis in pediatric patients receiving hematopoietic stem cell transplantation]. / Estudio retrospectivo de la aplicación de la amplificación génica cualitativa en muestras biológicas para el seguimiento de la toxoplasmosis en pacientes pediátricos receptores de trasplante de células progenitoras hematopoyéticas.

Toxoplasmosis is an opportunistic infection caused by the parasite Toxoplasma gondii. The infection is severe and difficult to diagnose in patients receiving allogeneic hematopoietic stem cell transplantation (HSCT). Twelve patients receiving HSCT were monitored post-transplant, by qualitative PCR at the Children's Hospital S.A.M.I.C. "Prof. Dr. Juan P. Garrahan". The monitoring of these patients was defined by a history of positive serology for toxoplasmosis in the donor or recipient and because their hematologic condition did not allow the use of trimethoprim-sulfamethoxazole for prophylaxis. During the patients' monitoring, two of them with positive PCR results showed signs of illness by T. gondii and were treated with pyrimethamine-clindamycin. In two other patients, toxoplasmosis was the cause of death and an autopsy finding, showing negative PCR results. Four patients without clinical manifestations received treatment for toxoplasmosis because of positive PCR detection. In four patients there were no signs of toxoplasmosis disease and negative PCR results during follow-up. The qualitative PCR technique proved useful for the detection of toxoplasmosis reactivation in HSCT recipients, but has limitations in monitoring and making clinical decisions due to the persistence of positive PCR over time and manifestations of toxicity caused by the treatment.

Post-transplant Pneumocystis jirovecii pneumonia--a re-emerged public health problem?

Pneumocystis jirovecii is a unicellular organism that in individuals with impaired immunity may cause pneumonia that can progress from minor illness to severe inflammatory pneumonia (PCP) with respiratory failure and death. Despite antimicrobial prophylaxis, which has reduced the incidence of PCP, clusters of late infections have been reported among kidney transplant recipients worldwide. A nosocomial PCP cluster was first recognized in 2010 at a Sydney hospital, but PCP clusters have since occurred in almost half of the renal transplant units on the eastern Australian seaboard, refocussing attention on optimal prophylaxis regimens and the likelihood of patient-to-patient transmission. A consensus meeting was conducted to derive the lessons from this experience for responding to PCP outbreaks. These included: (1) acting quickly--clusters of PCP in kidney transplant recipients with patient-to-patient transmission required transplant programs to act quickly to institute prophylactic and treatment measures; (2) instituting universal prophylaxis for all patients seen in the affected unit; (3) reducing patient-to-patient transmission via airborne droplets in the outpatient waiting areas; (4) examining the P. jirovecii genotypes. The meeting also considered recommendations for the duration of prophylaxis following de novo transplant and, for the individuals in whom long term prophylaxis is required, separating units with and without clusters of PCP.

[An epidemic strain of Acinetobacter baumannii in two long-term care facilities]. / Evento epidemico da Acinetobacter baumannii in pazienti lungodegenti.

This study describes an epidemic strain of Acinetobacter baumannii (AB) in two long-term care facilities. Assessment was focused on the spreading modalities of AB infection, the risk of acquiring the infection from colonized patients, the multidrug-resistant features, the clinical characteristics of affected patients, and the average length of hospital stay prior to and after AB infection. The effects of AB spreading among the healthcare operators and the environment are also evaluated, along with a description of the clinical course and outcome, and the efficacy of implemented preventive measures. AB is an opportunistic pathogen with increasing relevance in a variety of nosocomial infections.

Pneumocystis jirovecii infection: an emerging threat to patients with rheumatoid arthritis.

Accompanying the increased use of biologic and non-biologic antirheumatic agents, patients with RA have been exposed to an increased risk of Pneumocystis jirovecii infection, which causes acute fulminant P. jirovecii pneumonia (PCP). Mortality in this population is higher than in HIV-infected individuals. Several guidelines and recommendations for HIV-infected individuals are available; however, such guidelines for RA patients remain less clear. Between 2006 and 2008 we encountered a clustering event of P. jirovecii infection among RA outpatients. Through our experience with this outbreak and a review of the recent medical literature regarding asymptomatic colonization and its clinical significance, transmission modes of infection and prophylaxis of PCP, we have learned the following lessons: PCP outbreaks among RA patients can occur through person-to-person transmission in outpatient facilities; asymptomatic carriers serve as reservoirs and sources of infection; and short-term prophylaxis for eradication of P. jirovecii is effective in controlling PCP outbreaks among RA outpatients.

[New recommendations for contact tracing in tuberculosis]. / Neue Empfehlungen für die Umgebungsuntersuchungen bei Tuberkulose*1.

In 2007, the German Central Committee against Tuberculosis (DZK) published recommendations for contact tracing that introduced the new interferon gamma release assays (IGRAs). Meanwhile, substantial progress has been made in documenting the utility of IGRAs. Because IGRAs are usually superior to the tuberculin skin test (TST) in detecting latent TB infection (LTBI) with respect to sensitivity and specificity in adult contact populations that are at least partially BCG vaccinated, it is now recommended that instead of two-step testing only IGRAs be used.[nl]As the literature does not yet provide sufficient data on the accuracy of IGRAs in children younger than 5 years, the TST remains the method of choice in that age group. To date, also, no clear body of data exists to substantiate better performance for IGRAs than for the TST in older children, thus in this age group using of either test is recommended. The new recommendations also underscore the importance of a diligent preselection of close contacts in order to achieve a high probability that positive test results represent recent infection and to thus increase the benefit of chemopreventive treatment for those identified as requiring it. In a third point of update, it is noted that re-testing of contacts individuals found positive for LTBI may produce a considerable number of false-negative results and should thus be avoided in case of documented exposure.

Evaluation of the microbial flora found in woodwind and brass instruments and their potential to transmit diseases.

Previous studies of dental devices (toothbrushes, dentures, and protective athletic mouthguards) have demonstrated microbial contamination of these devices and possible transmission of infectious diseases to the users. Since woodwind and brass instruments come into intimate contact with the musician's oral cavity and often are passed from student to student without sanitization, the question arises as to whether these instruments are contaminated and can transmit microbial diseases. The purpose of this study was to determine if woodwind and brass instruments and/or their cases harbor opportunistic, pathogenic, or allergenic microorganisms that can be transmitted to the musician. The internal components of woodwind and brass instruments harbored opportunistic, pathogenic, and/or allergenic microorganisms. The highest concentrations of microorganisms were found consistently at the mouthpiece end, but there was evidence of contamination throughout the instruments and their cases. The close proximity of contaminated mouthpieces to the oral cavity could facilitate local and systemic dissemination of the resident opportunistic, pathogenic, and/or allergenic microorganisms. General dentists should determine whether patients play a brass or woodwind instrument and be aware of the possible impact of this activity on the oral cavity and the entire body.

[Vaccination against pneumococci and influenza. How good is the evidence?]. / Impfungen gegen Pneumokokken und Influenza. Wie groß ist die Evidenz?

Diseases caused by pneumococci and influenza viruses can lead to severe complications in children, in older, chronically ill and immunosuppressed patients. In an aging population in western countries they present an important cause of morbidity and mortality. Additionally, antibiotic resistance may complicate a therapy. Consequently, the need of an effective vaccine is obvious. The 23-valent polysaccharide pneumococcal vaccine has been discussed critically. New meta-analyses do not show an efficacy in preventing invasive pneumococcal disease or death of all cause. However, a very recent study has shown a significant reduction of pneumonias and death due to pneumococcal disease in nursing-home residents. The 7-valent conjugated vaccine is more immunogenic and efficient in children and first studies demonstrate its efficacy in immunosuppressed persons. In Switzerland this latter vaccine is used in children, in Germany the 7-valent vaccine has been replaced by the 13-valent conjugated vaccine since December 2009. Influenza-vaccines are effective, while vaccines with an adjuvance seem more immunogenic, in particular in older persons. The 2010/2011 influenza vaccine has been adapted and includes the pandemic influenza H1N1 2009 strain. The influenza vaccine often does not provide protection against infection, however, it does provide good efficacy against severe complications related to influenza.

[Septic shock in a renal transplanted patient after consumption of uncooked pork meat]. / Septischer Schock bei einem nierentransplantierten Patienten nach Genuss von rohem Schweinefleisch.

Salmonellosis caused by Salmonella enteritidis is an acute and in most cases zoonotic disease, but chronic human carriers are also known. Mostly, affected persons recover without treatment, but severe complications occur occasionally. For the first time we report a case of probably food-borne invasive Salmonella enteritidis infection with septic shock in a patient with Tacrolimus treatment, 13 years after renal transplantation, probably acquired by uncooked ground pork meat.

Transmission, adaptation and geographical spread of the Pseudomonas aeruginosa Liverpool epidemic strain.

The Liverpool epidemic strain (LES) is an important transmissible clonal lineage of Pseudomonas aeruginosa that chronically infects the lungs of people with cystic fibrosis (CF). Previous studies have focused on the genomics of the LES in a limited number of isolates, mostly from one CF centre in the UK, and from studies highlighting identification of the LES in Canada. Here we significantly extend the current LES genome database by genome sequencing 91 isolates from multiple CF centres across the UK, and we describe the comparative genomics of this large collection of LES isolates from the UK and Canada. Phylogenetic analysis revealed that the 145 LES genomes analysed formed a distinct clonal lineage when compared with the wider P. aeruginosa population. Notably, the isolates formed two clades: one associated with isolates from Canada, and the other associated with UK isolates. Further analysis of the UK LES isolates revealed clustering by clinic geography. Where isolates clustered closely together, the association was often supported by clinical data linking isolates or patients. When compared with the earliest known isolate, LESB58 (from 1988), many UK LES isolates shared common loss-of-function mutations, such as in genes gltR and fleR. Other loss-of-function mutations identified in previous studies as common adaptations during CF chronic lung infections were also identified in multiple LES isolates. Analysis of the LES accessory genome (including genomic islands and prophages) revealed variations in the carriage of large genomic regions, with some evidence for shared genomic island/prophage complement according to clinic location. Our study reveals divergence and adaptation during the spread of the LES, within the UK and between continents.

JMM Profile: Vibrio cholerae: an opportunist of human crises.

Vibrio cholerae O1 is the aetiological agent of the severe diarrhoeal disease cholera. Annually, there are an estimated 1-4 million cholera cases worldwide and over 140 000 deaths. The primary mode of disease transmission is through the consumption of water or food contaminated with the bacterium. Although cholera patients can be treated effectively using rehydration therapy, the disease remains a major scourge in areas with limited access to clean water and proper sanitation. Its continued prevalence highlights the failure of socioeconomic policies leading to wealth disparities, fragile and dated public infrastructure, and lack of appropriate health surveillance.

[Investigation of a neonatal case of Enterobacter sakazakii infection associated with the use of powdered infant formula]. / Investigación de un caso de infección neonatal por Enterobacter sakazakii asociada a un preparado en polvo para lactantes.

INTRODUCTION: The aim of this study was to describe the investigation of a case of meningitis in a neonatal intensive care unit in order to identify the source of infection and the associated risk factors. MATERIAL AND METHODS: An analysis was carried out on the possible risk factors associated with the infection. E. sakazakii was detected in the batch of the powdered infant formula used during the feeding of the neonate and the initial level of contamination of the microorganism was estimated. The strains of E. sakazakii previously isolated in blood and faeces of the infected neonate and those isolated in infant formula were characterised by biotype, pulsotype and antimicrobial susceptibility. RESULTS: E. sakazakii was detected in one opened and two unopened cases of a single batch of powdered infant formula. The E. sakazakii strains isolated in the samples of the product and those isolated in the infected neonate showed the same biochemical, antibiotic susceptibility and PFGE pattern. CONCLUSIONS: The case of meningitis in the neonatal intensive care unit occurred as a result of the use of a powered infant formula contaminated with E. sakazakii at manufacturing level, and an inadequate preparation and storing of the reconstituted product were identified as risk factors.

[Norovirus infections: an overview]. / Actualités sur les norovirus.

Noroviruses belong to the Caliciviridae family. They are a major cause of sporadic cases and outbreaks of gastroenteritis in all age groups, and are responsible for a considerable disease burden in industrialized countries. Noroviruses are single-stranded RNA viruses, and show great genetic diversity making their detection difficult. Noroviruses can be divided into 5 genogroups, which themselves are subdivided into genotypes. Besides chance mutations that occur during viral replication, the great heterogeneity observed among noroviruses is also due to intra and inter-genotypic recombination events between strains. Some of these new variants or new recombinants are frequently associated with new epidemic waves of gastroenteritis. Finally, it is worth pointing out that the discovery of mechanisms involved in NoV infections through blood antigen-related receptors and cultivation of the first norovirus, a murine norovirus, are milestones in research on this virus. These advances open new promising avenues of research that will help to the understanding of the -pathogenicity of this important pathogen.