[Meningoencephalitis and ventricular arrhythmia caused by yersiniosis]. / Meningoenzephalitis und ventrikuläre Rhythmusstörungen bei Yersiniose.

We report on a 19-year-old patient without any immunodeficiency and without a history of significant diseases in whom two seizure attacks as symptoms of meningoencephalitis occurred after he had suffered from abdominal symptoms for a week. Later, we could observe frequent polymorphic ventricular extrasystoles. A massive production of anti-Yersinia IgM, IgG and IgA as a sign of an acute infection could be found, although we were not able to detect the microbe itself with culturing methods. After targetted antibiotic treatment, the patient fully recovered within two weeks and could be discharged from hospital without clinical abnormalities and an almost normalised cell count in the cerebrospinal fluid. Possible ways of infection are mice which the patient kept as pets and his work in the sewer system. The present case reminds us to think of uncommon infectious agents even in young patients without a predisposition but unusual symptoms and/or potentially relevant anamnestic data.

[Infection control in the operating room: preventive measures and isolation precautions in cases of multidrug resistant pathogens]. / Infektionskontrolle im OP: Präventions- und Isolierungsmaßnahmen bei multiresistenten Erregern.

BACKGROUND: Providing surgical treatment for patients colonised or infected with multidrug resistant organisms (MDROs) is daily routine in German hospitals. However, there is uncertainty about the application of adequate infection control measures in the OR. One of the reasons is that specific guidelines are not available. MATERIAL AND METHODS: We evaluated current practice in surgical departments of selected German university medical centres using a questionnaire. In addition, centres were asked to provide in-house standard operating procedures (SOP), if available. RESULTS: Nineteen questionnaires from 19 departments within 4 centres and 5 in-house SOPs were ana-lysed. The results showed a broad spectrum of applied infection control measures. Wide variations existed both within centres and within departments of the same centre regardless of existing in-house standards. CONCLUSIONS: Guidelines addressing perioperative infection control measures for patients harbouring MDROs should be developed with a focus on practicability to reduce both transmission of MDROs and unreasonable measures. Implementation of existing SOPs can be a target for optimisation.

[Multi-dose packaging of drugs as the causative vehicle for multidrug-resistant Enterobacter cloacae: new results from a case-control study]. / Mehrfach-Verpackungen oraler Medikamente als Ausbruchsvehikel multiresistenter Enterobacter cloacae: neue Erkenntnisse durch eine Fall-Kontroll-Studie.

Hospital hygiene faces cross-cutting and methodological challenges that are time consuming and require specialised knowledge. In outbreak situations German federal states can request assistance from infectious disease epidemiologists at the Robert Koch Institute (RKI). The presented study describes the successful collaboration of local hygienists, microbiologists, clinicians, health authorities and the epidemiologists of the RKI in the investigation of an outbreak of multidrug-resistant Enterobacter (E.) cloacae in 2009 in a children's hospital. The outbreak was discovered in July 2009 when E. cloacae was detected in 12 patients in the neonatal and paediatric intensive care unit (NICU). Hygiene measures were intensified for infection control, and the RKI was invited by the responsible regional health authorities in October 2009 to assist in the outbreak investigation. We conducted a retrospective matched case-control study to identify risk factors for E. cloacae colonisation and infection. We identified a case as any child in the NICU from 1st May to 5th October 2009 with laboratory confirmation of the outbreak clone. Controls were patients staying in the NICU (> 72 h before the case's diagnosis) and swab-negative for the outbreak clone. We used standardised questionnaires to collect demographic and medical information. Matched odds ratios (mOR) were calculated by bivariate and multivariable conditional logistic regression. Environmental investigations were conducted. We identified 28 colonised and 3 bacteraemic cases. 29 matched case-control pairs were included in the study. Multivariable analysis revealed an association between E. cloacae diagnosis and the receipt of oral drugs at the bed-side from multidose packaging (mOR=1.8/drug; p=0.006). No specific drug was identified; microbiological investigation of drugs was negative. This multiresistant E. cloacae outbreak was most likely distributed by oral application using contaminated multidose drug packaging extrinsically contaminated via hands of personnel. No further cases occurred for 6 weeks after protocols for handling oral drugs were changed (smaller packaging, patient-based storage, and limited circulation time). Special attention and thorough hygiene protocols are needed for the distribution of oral medication. In NICUs the use of multi-dose medications should be avoided. The cooperation between locally available expertise and infectious disease epidemiologists enabled the discovery of a previously unidentified risk factor.

[Methicillin-resistant Staphylococcus (MRSA, MRSE) in the nose, paranasal sinuses and sputum]. / Methicillinresistente Staphylokokken (MRSA, MRSE) im Nasen-, Nasennebenhöhlenbereich und Sputum.

Detection of Staphylococcus in humans can be of extremely varying importance ranging from commensal to pathogens of fatal infections. MRSAs in particular are iatrogenic and nosocomial infective pathogens, which are a threat to the success of medical treatment. In this review the causes for occurrence and the spread of MRSA are presented and the heterogeneity of MRSA due to the presence of additional resistant pathogens (VISA, VRSA) and pathogenetic forms (cMRSA) will be discussed. The current diagnostic and therapeutic procedures in various situations for MRSA in the nasal and paranasal sinuses and sputum will be discussed exemplified by an actual case. The danger of colonization by MRSA will be discussed with reference to the literature as nasal colonization can be accompanied by a greatly increased risk of an invasive infection and transmission of the pathogen to other persons.

[Methicillin-resistant Staphylococcus aureus. Types of resistance and clinical consequences]. / Methicillin-resistente Staphylococcus aureus Resistenztypen und klinische Konsequenzen.

The problem of methicillin-resistant Staphylococcus aureus (MRSA) is on the rise worldwide. However, significant regional differences exist with respect to incidence, types of prevalent outbreak strains and accompanying resistance patterns as well as local conditions and resources to control epidemics. Intensive care units are regularly epicenters of MRSA epidemics. Accordingly, anaesthesists, intensive care physicians and surgeons need to know the established recommendations and guidelines about early recognition and infection control of MRSA, must be familiar with principles of the antimicrobial MRSA therapy, and should adapt the principles for prevention and therapy of MRSA infections to the needs of the respective institution and situation. The result of this process has to be a rational and efficient approach to this nosocomial pathogen allowing its control under consideration of cost effectiveness.

[The infected implant: bacteriology]. / Das infizierte Implantat: Bakteriologie.

Periprosthetic infection is a significant complication in joint replacement surgery and develops in 0.5%-2% cases. Staphylococcus aureus and commensal microorganisms of the skin, especially coagulase-negative staphylococci, as well as a broad spectrum of other potential pathogens typically already colonize the surface of the foreign body at the time of implantation. Specific mechanisms such as bacterial adhesion to host factors absorbed in the material, biofilm formation, and a metabolic adaptation of adherent microorganisms play a paticulary important role in the pathogenesis and course of the disease. Microbiological diagnosis requires to some extent complex culture procedures of puncture specimens or tissue removed during surgery; this can be supplemented by modern molecular testing. Antimicrobial treatment must be conceived as a synopsis of clinical picture, confirmed pathogen, and the intended surgical procedure on an individual basis and is routinely administered as combination therapy for several weeks, sometimes also as sequential therapy. Validated preventive measures in joint replacement surgery include mandatory perioperative antibiotic prophylaxis and other additional measures.

[The infected implant. Part 1: bacteriology]. / Das infizierte Implantat. Teil 1. Bakteriologie.

Periprosthetic infection is a significant complication in joint replacement surgery and develops in 0.5-2% of cases. Staphylococcus aureus and commensal microorganisms of the skin, especially coagulase-negative staphylococci, as well as a broad spectrum of other potential pathogens typically already colonize the surface of the foreign body at the time of implantation. Specific mechanisms such as bacterial adhesion to host factors absorbed in the material, biofilm formation, and a metabolic adaptation of adherent microorganisms play a particularly important role in the pathogenesis and course of the disease. Microbiological diagnosis requires to some extent complex culture procedures of puncture specimens or tissue removed during surgery; this can be supplemented by modern molecular testing. Antimicrobial treatment must be conceived as a synopsis of clinical picture, confirmed pathogen, and the intended surgical procedure on an individual basis and is routinely administered as combination therapy for several weeks, sometimes also as sequential therapy. Validated preventive measures in joint replacement surgery include mandatory perioperative antibiotic prophylaxis and other additional measures.

ADP-ribosylation of an approximately 70-kilodalton protein of Klebsiella pneumoniae.

An approximately 70-kDa protein in the culture supernatant of a human pathogenic strain of Klebsiella pneumoniae was labeled in the presence of [32P-adenylate]NAD. Labeling was significantly increased by the addition of dithiothreitol ( > 1 mM) but prevented by treatment of the culture supernatant for 3 min at 56 degrees C. The addition of unlabeled NAD, but not of ADP-ribose, blocked labeling of the approximately 70-kDa protein. The radioactive label was released by formic acid but not by HgCl2 (1 mM) or neutral hydroxylamine (0.5 M). The addition of homogenates of human platelets, human neutrophils, rat brain, rat lung, or rat spleen tissues to the culture supernatant did not induce labeling of eukaryotic proteins. The data indicate that the K. pneumoniae strain produces ADP-ribosyltransferase which modifies an endogenous protein.

Inhibition of cytochalasin D-stimulated G-actin ATPase by ADP-ribosylation with Clostridium perfringens iota toxin.

Clostridium perfringens iota toxin belongs to a novel family of actin-ADP-ribosylating toxins. The effects of ADP-ribosylation of skeletal muscle actin by Clostridium perfringens iota toxin on cytochalasin D-stimulated actin ATPase activity was studied. Cytochalasin D stimulated actin-catalysed ATP hydrolysis maximally by about 30-fold. ADP-ribosylation of actin completely inhibited cytochalasin D-stimulated ATP hydrolysis. Inhibition of ATPase activity occurred at actin concentrations below the critical concentration (0.1 microM), at low concentrations of Mg2+ (50 microM) and even in the actin-DNAase I complex, indicating that ADP-ribosylation of actin blocks the ATPase activity of monomeric actin and that the inhibitory effect is not due to inhibition of the polymerization of actin.

Laminin and aminoterminal propeptide of type III procollagen in seminal plasma from fertile and vasectomized men.

The components of the extracellular matrix, laminin and aminoterminal propeptide of type III procollagen (PIIINP) were determined in seminal plasma of 50 patients with vasectomy and of 50 age-matched fertile patients. The concentration of laminin was highly significantly (P < 0.001) elevated in the fertile group as compared to the vasectomy group, whereas the concentrations of PIIINP were not significantly different between these two groups. Only weak correlations were observed between the concentrations of laminin and PIIINP. It is suggested that part of the laminin found in seminal plasma is derived from the ductus deferens, while the source of PIIINP is probably located at an upper part of the urogenital tract.

PIP: The aim was to examine the effect of the resection of the ductus deferens on the pattern of extracellular matrix components in seminal plasma. The components laminin and aminoterminal propeptide of type III procollagen (PIIINP) were determined in seminal plasma of 50 patients with vasectomy and of 50 age-matched fertile patients. Fifty ejaculates from normal fertile men and 50 ejaculates from patients with vasectomy were randomly selected from a pool of clinical specimens at the Kantonsspital Aarau, Switzerland. Age ranges were between 19 and 43 years. Laminin was measured with a competitive radio immunoassay using a rabbit antiserum against the pepsin-resistant fragment P1 of human laminin. PIIINP was measured with a new radioimmunoassay using monoclonal antibodies against the aminoterminal propeptide in a 2-stage sandwich assay. Laminin and PIIINP could be detected in all seminal plasma of the fertile group and the vasectomy group, respectively. The median concentration of laminin in seminal plasma was 1.98 kU per liter in the fertile group and 1.25 kU per liter in the vasectomy group. The median concentration of PIIINP in the seminal plasma of the fertile group was 0.59 kU per liter and 0/52 kU per liter in the vasectomy group. For laminin the concentration levels in the fertile and the vasectomy group were significantly different (P or= 10 -7). No significant differences were obtained for PIIINP (P 0.05). The concentration of laminin was very significantly (P 0.001) elevated in the fertile group as compared to the vasectomy group, whereas the concentration of PIIINP were not significantly different. In the combined groups, a weak correlation between laminin an PIIINP was observed (P 0.05). This correlation was even lower in the fertile group (P 0.05), whereas within the vasectomy group it was slightly higher. If results can be verified in larger groups of patients with aspermia caused by testicle disorders and by a block of the ductus deferens, the determination of laminin in seminal plasma might prove useful as an adjuvant diagnostic measure.

The concentration pattern of laminin, hyaluronan, and aminoterminal propeptide of type III procollagen in seminal fluid.

The extracellular matrix components laminin, N-terminal propeptide of type III procollagen (PIIINP) and hyaluronan (HA) were determined in seminal fluids of 119 patients submitted for diagnosis of infertility. The concentrations of laminin and HA, but not those of PIIINP, were elevated in seminal fluid in comparison to their ranges of concentration in normal sera. Only weak correlations were observed between the concentrations of the three matrix components. The concentration of HA was negatively correlated with sperm count and ejaculate volume. Laminin was positively correlated with sperm count, the age of patients, and highly significantly with the concentrations of acrosin. A highly significant positive correlation was also found between PIIINP and fructose. By analysis of variance it could be shown that patients with azoospermia and oligozoospermia have significantly higher levels of HA than those with normospermia. Patients with terato- and asthenozoospermia showed no characteristic pattern of the matrix components.

A cluster of nosocomial cross-infection due to multiple antibiotic-resistant Acinetobacter baumannii: Characterization of the strain and antibiotic susceptibility studies.

A multiple antibiotic-resistant (MAR) strain of Acinetobacter baumannii caused nosocomial cross-infection among 3 patients of a surgical intensive care unit. The isolates were of identical biochemical profile (77776 S-U-) and serotype (serovar 36) and identical in terms of pulsed-field gel electrophoresis macrorestriction (SmaI, ApaI) analysis. This MAR strain was susceptible only to netilmicin, tobramycin, imipenem, meropenem, polymyxin B, and trovafloxacin. The minimal bactericidal concentrations of imipenem and meropenem were markedly higher than the corresponding minimal inhibitory concentrations against this strain. Combined fresh defibrinated human blood (65 vol%) and antimicrobial drug assays yielded the following results: polymyxin was the most rapidly bactericidally effective antibiotic in the presence of blood and in broth. Tobramycin and netilmicin were efficacious in 65 vol% blood. Imipenem was slightly more effective than meropenem in broth, whereas both carbapenems sterilized blood-containing assay tube contents. Trovafloxacin failed to achieve bactericidal activity (to 99.9% kill) in the presence of blood, presumably because this strain was resistant to ciprofloxacin and borderline susceptible to ofloxacin. Trovafloxacin combined with either imipenem or meropenem yielded an indifferent effect. However, the combination of trovafloxacin (2 microg/ml) plus tobramycin (1 microg/ml) achieved sterilization of tube contents in the presence of blood within 4 h after exposure and in broth following extended (overnight) incubation. This MAR strain of A. baumannii was high-level resistant to rifampin; thus the combination of polymyxin B plus rifampin proved indifferent.

Antibiotic susceptibility testing (agar disk diffusion and agar dilution) of clinical isolates of Enterococcus faecalis and E. faecium: comparison of Mueller-Hinton, Iso-Sensitest, and Wilkins-Chalgren agar media.

Forty-two isolates of Enterococcus faecalis and 56 isolates of Enterococcus faecium, including 8 vancomycin-resistant strains, were examined for comparative susceptibility to 27 antimicrobial drugs with the agar dilution method, employing Mueller-Hinton (MHA), Iso-Sensitest (ISTA), and Wilkins-Chalgren (WCA) agar. The Bauer-Kirby agar disk diffusion method was used to comparatively test 24 of the agents in parallel. The enterococci yielded better growth on ISTA and WCA. However, WCA completely antagonized co-trimoxazole and, though less, fosfomycin. Importantly, WCA slightly reduced the activities of teicoplanin (minimal inhibitory concentrations, MICs, raised up to twofold) and vancomycin (MICs raised two- to fourfold) against enterococci and staphylococcal quality control strains. Therefore, WCA was judged unsuitable for susceptibility testing of enterococci. For E. faecalis no discrepancies between agar dilution MICs and inhibition zone diameters were encountered with augmentin, ampicillin, ampicillin-sulbactam, chloramphenicol, mupirocin, oxacillin, teicoplanin, and co-trimoxazole. Overall, MHA yielded fewer very major (category I) and major (category II) discrepancies than ISTA. However, numerous minor (category III), slight (category IV), minimal (category V), and/or negligible (category VI) discrepancies were encountered with ciprofloxacin, doxycycline, erythromycin, fosfomycin, fusidic acid, meropenem, ofloxacin and rifampin. With respect to E. faecium, only cefotaxime, mupirocin, oxacillin, and teicoplanin yielded nondiscrepant results. Several very major (I) and major (II) discrepancies were observed with augmentin, ampicillin, ampicillin-sulbactam, doxycycline, fusidic acid, imipenem, and penicillin G. Minor discrepancies (categories III-VI) were particularly numerous with augmentin, chloramphenicol, ciprofloxacin, doxycycline, and piperacillin. The largest numbers of negligible (VI) discrepancies were noted with fosfomycin, fusidic acid, and ofloxacin. It is recommended to test one cephalosporin (cefuroxime or the like) in parallel for educational purposes and to exclude fosfomycin, fusidic acid, and rifampin from test batteries because of the wide scatter of test results. The large number of minimal (V) discrepancies of ciprofloxacin against E. faecalis, the numerous minor (III) and slight (IV) discrepancies of chloramphenicol against E. faecium, and the not insignificant number of very major (I) and minor (III) discrepancies observed with meropenem against isolates of E. faecalis necessitated proposals for new disk intermediate susceptibility criteria.

Antibiotic susceptibility testing (agar disk diffusion and agar dilution) of clinical isolates of Corynebacterium jeikeium.

Thirty-three clinical isolates of Corynebacterium jeikeium were examined for susceptibility to 27 antimicrobial drugs with the agar dilution test. Sheep-blood-supplemented Mueller-Hinton agar performed better than Wilkins-Chalgren agar. Disk susceptibility (Bauer-Kirby) tests were carried out in parallel with 24 of the chemotherapeutic agents. All isolates were susceptible to teicoplanin and vancomycin. All isolates resisted fosfomycin, mupirocin, and trimethoprim-sulfamethoxazole. The isolates varied in susceptibility to ciprofloxacin, doxycycline, fusidic acid, ofloxacin, and tetracycline; most were susceptible to rifampin. Surprisingly few discrepancies between agar dilution and disk diffusion tests were encountered when utilizing NCCLS interpretive criteria currently valid for enterococcal isolates.

De-ADP-ribosylation actin by Clostridium perfringens iota-toxin and Clostridium botulinum C2 toxin.

The reverse reaction of the ADP-ribosylation of actin by Clostridium botulinum C2 toxin and Clostridium perfringens iota-toxin was studied. In the presence of nicotinamide (30-50 mM) C2 toxin and iota-toxin decreased the radioactive labeling of [32P]ADP-ribosylated actin and catalyzed the formation of [32P]NAD. The pH optima for both reactions were 5.5-6.0. Concomitant with the removal of ADP-ribose, the ability of actin to polymerize was restored and actin ATPase activity increased. Neither ADP-ribosylation nor removal of ADP-ribose was observed after treatment of actin with EDTA, indicating that the native structure of actin is required for both reactions. ADP-ribosylation of platelet actin by C2 toxin was reversed by iota-toxin, confirming recent reports that both toxins modify the same amino acid in actin. However, C. botulinum C2 toxin was not able to cleave ADP-ribose from skeletal muscle actin which had been incorporated by iota-toxin, corroborating the different substrate specificities of both toxins.

Characterization of the ADP-ribosylation of actin by Clostridium botulinum C2 toxin and Clostridium perfringens iota toxin.

Clostridium botulinum C2 toxin and Clostridium perfringens iota toxin belong to a novel family of actin ADP-ribosylating toxins. ADP-ribosylation of actin inhibits actin polymerization and G-actin-associated ATPase activity. The ADP-form of actin is ADP-ribosylated at a higher rate than actin with bound ATP. ADP-ribosylation of actin is reversible, a reaction, which is accompanied by reconstitution of actin ATPase activity.

ADP-ribosylation of actin causes increase in the rate of ATP exchange and inhibition of ATP hydrolysis.

ADP-ribosylation of skeletal muscle actin by Clostridium perfringens iota toxin increased the rate of exchange of actin-bound [gamma-32P]ATP by unlabelled ATP about twofold. Increased exchange rates were observed with ATP and ATP[gamma S], much less with ADP but not with AMP or NAD. ADP-ribosylation of skeletal muscle actin reduced "basal" and Mg2+ (1 mM)-induced ATP hydrolysis by about 80%. Similar inhibition of ATP hydrolysis was observed with liver actin ADP-ribosylated by Clostridium botulinum C2 toxin. The data indicate that ADP-ribosylation of actin at Arg-177 largely affects the ATP-binding and ATPase activity.

ADP-ribosylation of skeletal muscle and non-muscle actin by Clostridium perfringens iota toxin.

The enzymatically active component ia of Clostridium perfringens iota toxin ADP-ribosylated actin in human platelet cytosol and purified platelet beta/gamma-actin, in a similar way to that been reported for component I of botulinum C2 toxin. ADP-ribosylation of cytosolic and purified actin by either toxin was inhibited by 0.1 mM phalloidin indicating that monomeric G-actin but not polymerized F-actin was the toxin substrate. Perfringens iota toxin and botulinum C2 toxin were not additive in ADP-ribosylation of platelet actin. Treatment of intact chicken embryo cells with botulinum C2 toxin decreased subsequent ADP-ribosylation of actin in cell lysates by perfringens iota or botulinum C2 toxin. In contrast to botulinum C2 toxin, perfringens iota toxin ADP-ribosylated skeletal muscle alpha-actin with a potency and efficiency similar to non-muscle actin. ADP-ribosylation of purified skeletal muscle and non-muscle actin by perfringens iota toxin led to a dose-dependent impairment of the ability of actin to polymerize.