Biofilm formation and antibiotic resistance in Klebsiella pneumoniae urinary strains.

AIMS: Multidrug-resistant Klebsiella pneumoniae has become a relevant healthcare-associated pathogen. Capsule, type 1 and 3 fimbriae (mrkA gene), type 2 quorum-sensing system (luxS), synthesis of D-galactan I (wbbM), LPS transport (wzm) and poly-beta-1,6-N-acetyl-D-glucosamine (pgaA) seem involved in K. pneumoniae biofilm. Nonenzymatic antibiotic resistance is related to nonexpression or mutation of porins (OmpK35 and OmpK36), and efflux pump (acrB) overexpression. The aim of this study was to analyse some virulence factors of K. pneumoniae isolates, and to evaluate possible correlations between their antibiotic resistance profile and ability to form biofilm. METHODS AND RESULTS: Quantitative biofilm production assay, congo red agar test and string test were performed on 120 isolates clustered in 56 extensively drug-resistant (XDR), 40 MDR and 24 susceptible (S) strains. Nine representative strains were analysed by real-time RT-PCR for the expression of antibiotic resistance (OmpK35, OmpK36, acrB) and biofilm production genes (mrkA, luxS, pga, wbbM, wzm) during planktonic and sessile growth. XDR isolates showed a higher ability to form biofilm (91·07%) and to produce polysaccharides (78·57%) when compared to MDR and S strains. In biofilm-growing XDR strains, seven of eight genes were upregulated, with the only exception of OmpK36. CONCLUSIONS: XDR strains exhibited phenotypic and genotypic features supporting a significant growth as biofilm. SIGNIFICANCE AND IMPACT OF THE STUDY: This study produces new findings that highlight a positive correlation between antibiotic resistance profile and biofilm-forming ability in XDR K. pneumoniae strains. These new evidences might contribute to the progress in selection of therapeutic treatments of infections caused by K. pneumoniae resistant also to the 'last line of defence' antibiotics, that is, carbapenems.

Staphylococcal endo-beta-N-acetylglucosaminidase inhibits response of human lymphocytes to mitogens and interferes with production of antibodies in mice.

The effect of a bacteriolytic enzyme, the endo-beta-N-acetylglucosaminidase excreted by Staphylococcus aureus (SaG) on the response of human lymphocytes to mitogens and on the immune response in mice has been studied. SaG inhibited incorporation of [3H]thymidine into TCA-precipitable material by human peripheral lymphocytes stimulated either by phytohemagglutinin or by concanavalin A, as well as formation of cytoplasmic immunoglobulin-containing cells by B lymphocytes treated with pokeweed mitogen. In all cases the level of inhibition first increased with the SaG concentrations reaching values of over 80% at an enzyme concentration of 100 micrograms/ml, and then decreased. Heat-inactivated SaG as well as SaG treated with both polyclonal and monoclonal specific antibodies or enzyme inhibitors such as chitotriose or hydrolyzed peptidoglycan had no effect on lymphocyte response to mitogens. In mice, SaG at a dose of 300 micrograms per mouse was found to cause a fourfold decrease in the anti-BSA antibody titer and an approximately 70-75% reduction in the immunoglobulin-containing cells in the spleens of mice injected with sheep red blood cells. SaG also completely abolished the enhancing effect of adjuvants such as muramyldipeptide, Freund's complete adjuvant, and Escherichia coli lipopolysaccharide. When SaG was injected into mice together with S. aureus peptidoglycan hydrolyzed either by SaG or by human lysozyme, the inhibitory effect on both production of anti-BSA circulating antibodies and appearance of Igc cells in the spleens of mice injected with sheep red blood cells was enhanced. As we know that (a) human tissues contain endo-beta-N-acetylglucosaminidases; (b) other human hexosaminidases (lysozymes) have previously been shown to interfere with the functions of immunocompetent cells; and (c) products of hexosaminidase hydrolysis of peptidoglycan (muropeptides) known to modulate immune response are ordinarily found in the urine of healthy persons, the possibility that hexosaminidases play a major role in the regulation of the immune response is raised and discussed.

Antibiotic susceptibility and serotype distribution in Streptococcus pneumoniae circulating in Italy: results of the SEMPRE surveillance study (2000-2002).

During 2000-2002, 20 clinical microbiology centres collected 1623 Streptococcus pneumoniae isolates. Susceptibility to penicillin, amoxicillin, amoxicillin/clavulanic acid, cefaclor, cefuroxime, cefotaxime, clarithromycin, ciprofloxacin, levofloxacin, rifampicin and teicoplanin was determined locally by the Etest and/or by the microdilution method by three co-ordinating centres. Total resistance to penicillin increased from 15.2% to 16.1% and macrolide resistance increased from 37.9% to 43.7%. Overall, the most effective drugs (>99% susceptible strains) were amoxicillin, amoxicillin/clavulanic acid, levofloxacin and rifampicin. The most frequent serotypes were: 23F (15.8%), 3 (10.8%) 14 (9.1%), 19F (9.1%), 6B (7.2%), 19A (6.9%) and 6A (4.8%). In conclusion, penicillin and macrolide resistance is increasing in Italy, whilst fluoroquinolone currently remains active. The most common serotypes circulating are included in the heptavalent conjugate vaccine, with the exception of type 3.

Interpretive criteria for disk diffusion susceptibility testing of ulifloxacin, the active metabolite of prulifloxacin.

Prulifloxacin, a new fluoroquinolone, is a prodrug whose active compound, ulifloxacin, is derived from its transformation after oral administration and intestinal absorption. Based on early pharmacokinetic and pharmacodynamic data, the following MIC breakpoints have tentatively been proposed: < or = 1 microg/ml, susceptible; 2 microg/ml, intermediate; and > or = 4 microg/ml, resistant. In this report, ulifloxacin MIC vs. zone diameter scattergrams and discrepancy rates were analyzed in 461 freshly isolated clinical strains (237 Enterobacteriaceae, 101 nonfermenters, and 123 Gram-positive bacteria). In agreement with the guidelines of the National Committee for Clinical Laboratory Standards, a modification of the error rate-bounded method was used to select disk diffusion test breakpoints. The following zone diameter breakpoints were chosen and are proposed herein for the interpretation of ulifloxacin disk (5 microg) test results: < or = 15 and > or = 19 mm for Enterobacteriaceae, < or = 16 and > or = 20 mm for nonfermenters, and < or = 14 and > or = 18 mm for Gram-positive bacteria. By applying these breakpoint values, no very major errors were detected, while major and minor errors were largely below the accepted discrepancy rates.

Quantitative evaluation of the recombinant HIV-1 phenotype to protease inhibitors by a single-step strategy.

OBJECTIVE: To develop and optimize a fast and quantitative recombinant strategy for evaluating the HIV-1 phenotype to protease inhibitors (PI). DESIGN AND METHODS: A non-replicative HIV-1 molecular vector (designated pdelta prodelta env) capable of expressing exogenous HIV-1 protease-encoding sequences was developed in this study. The HIV-1 protease sequences were amplified from either viral isolates or plasma samples (both from 21 HIV-1-infected individuals, 19 of whom were failing different anti-HIV-1 combination treatments) and cloned in the pdelta prodelta env backbone. The HIV-1 recombinant phenotype to PI was determined directly after transfection of viral chimeric clones by measuring protease activity and calculating a percentage sensitivity index (SI%; the ratio between the results from each clone and those from a PI-sensitive reference strain). RESULTS: The SI% values obtained from the recombinant clones paralleled the IC50 results of the viral isolates and documented different degrees of resistance and cross-resistance to PI, compatible, with few exceptions, with the respective genotype. Interestingly, an inverse correlation between SI% values and the presence of primary mutations for resistance to PI (P = 0.0038 and P = 0.0414, for indinavir and ritonavir, respectively) and a difference in SI% between samples harbouring an increasing number of mutations (indinavir, P = 0.022; ritonavir, P = 0.0466) were observed. CONCLUSION: The data substantiate the reliability of the novel strategy for a fast (5 day) quantitative evaluation of HIV-1 phenotype to PI, and indicate that this method may contribute to the understanding of mechanisms of virus resistance to PI.

Detection of bacterial phosphatase activity by means of an original and simple test.

A new test for the detection of bacterial phosphatase activity has been devised. The test is performed using agar media containing both methyl green (MG) and phenolphthalein diphosphate (PDP); in these media phosphatase-producing strains grow deep-green-stained colonies whereas non-producing strains do not. A total of 739 different strains were tested, including 593 staphylococci, 95 micrococci, 11 streptococci, 10 corynebacteria, 14 enterobacteria, and 16 candidae. All strains found phosphatase-positive according to the conventional phosphatase test displayed deep-green-stained colonies on MG-PDP media, whereas all phosphatase-negative strains showed unstained colonies on the same media. The main advantages of the present phosphatase test as compared with other conventional ones are that it is more simple to perform, it can reveal the phosphatase activity of colonies grown in deep agar, and can be incorporated into commercial multitest kits.

Clinical distribution and antibiotic sensitivities of staphylococcal strains isolated over an eight-month period.

A total of 842 staphylococci isolated from clinical material over an eight-month period and regarded as probable pathogens were identified according to lyogroup. Almost half the isolates belonged to lyogroups other than lyogroup I (Staphylococcus aureus), suggesting that coagulase-negative staphylococci are increasingly involved in human infections. All isolates were tested for sensitivity to 12 antibiotics. A greater resistance was observed in non-lyogroup I isolates, which again suggests a pathogenic significance of coagulase-negative staphylococci. Only lyogroup I strains, however, were obtained more frequently from clinical isolates than from healthy human skin. The distribution of the isolates in each lyogroup according to their clinical source is reported.

Detection of hepatitis B virus DNA in serum using synthetic non-radioactive oligonucleotides.

A rapid and simplified technique for detecting hepatitis B virus (HBV) DNA by spot hybridisation in the sera of patients with different clinical forms of HBV infection was investigated using enzyme conjugated synthetic oligodeoxyribonucleotides as probes. These are able to hybridize to the S and C regions of the HBV L(-) DNA strand. When compared with a complete 32P-labelled HBV DNA probe, the synthetic oligonucleotides provided a sensitive and quick method for the routine survey of HBV infection. Moreover, the DNA extraction procedure used allowed the spot hybridisation technique to be applied and read easily and the results obtained within a few hours. It is concluded that synthetic cold probes can be used in hybridisation assays HBV DNA detection as part of current clinical laboratory procedures.

Borderline susceptibility to methicillin in Staphylococcus aureus: a new mechanism of resistance?

Staphylococcus aureus strains with borderline levels of susceptibility or resistance to antistaphylococcal penicillinase-resistant penicillins (PRPs) were initially reported as neither heteroresistant nor multiply resistant organisms, producing large amounts of beta-lactamase, and becoming fully susceptible to PRPs in the presence of beta-lactamase inhibitors. This borderline susceptibility or low-level resistance was suggested to be due to beta-lactamase hyperproduction: according to this hypothesis, the staphylococcal beta-lactamase, when hyperproduced, would succeed in partially hydrolyzing methicillin and related PRPs. However, later studies demonstrated that borderline PRP susceptibility cannot be explained soley on this basis, beta-lactamase hyperproduction being neither sufficient nor necessary to determine the borderline phenotype. Intrinsic mechanisms have also been reported to be associated with some borderline PRP susceptible S. aureus strains. The more recent discovery of a PRP-hydrolyzing beta-lactamase (methicillinase) produced, in addition to the conventional penicillinase, by borderline S. aureus strains suggests that this second, more specific beta-lactamase is more likely to be responsible for the borderline phenotype than an increased amount of the penicillinase. The slow kinetics of PRP hydrolysis by methicillinase is consistent with its association with reduced susceptibility rather than true resistance to PRPs. The combined effect of methicillinase plus penicillinase on some common substrates might explain the increased beta-lactamase activity often observed in borderline S. aureus strains.

Genotypic characterization of a nosocomial outbreak of VanA Enterococcus faecalis.

Despite growing concern about vancomycin-resistant enterococci (VRE) as nosocomial pathogens, especially in the United States, in Italy VRE still represent an uncommon and occasional experience for most diagnostic laboratories. We report a genotypic characterization of the first reported nosocomial outbreak of VRE in Italy. Some experiments, including plasmid analysis and pulsed-field gel electrophoresis (PFGE) assays, aimed at investigating the genetic relatedness of the VRE isolates. Other experiments, based on hybridization and polymerase chain reaction (PCR) assays, aimed at characterizing the vancomycin resistance determinants. Over a 6-month period, 21 VRE, all identified as Enterococcus faecalis, were isolated from eight patients (all treated earlier with glycopeptide antibiotics) in a neurosurgical intensive care unit. All isolates had the same biochemical profile and antibiotic susceptibility pattern, including high-level resistance to aminoglycosides and vancomycin and teicoplanin MICs of 256 and 128 micrograms/ml, respectively. Three plasmids, one strongly hybridizing with a vanA probe, were detected in all but the last of the 21 VRE isolates. The last isolate of the cluster lacked the smallest of the three plasmids. Similar restriction profiles were obtained after plasmid DNA digestion with several endonucleases, with minor differences appreciated only in the first and last isolates. Analysis of genomic DNA restriction fragment patterns by PFGE confirmed that the reported cluster of VRE isolations was due to a single nosocomial strain of E. faecalis, despite some modifications in plasmid DNA at the beginning and at the end of the outbreak. Completely different PFGE patterns were yielded by vancomycin-susceptible E. faecalis strains isolated during the same period from inpatients in the same intensive care unit. Hybridization experiments with vanA and vanS-vanH probes and DNA amplification assays using 14 PCR primer pairs specific for vanA cluster genes (vanR, vanS, vanH, vanA, and vanY), orf1, orf2, vanB, and vanC showed identical organization of resistance determinants in all epidemic VRE isolates. This organization appeared to be the same as that described for Tn1546 in VanA prototype strain E. faecium BM4147.

An electron microscopic study of clinical and laboratory-derived strains of teicoplanin-resistant Staphylococcus haemolyticus.

Staphylococcal resistance to glycopeptides (which involves more teicoplanin than vancomycin) is uncommon and largely confined to Staphylococcus haemolyticus, an emerging nosocomial pathogen with a tendency to develop antibiotic resistance. In this study, six S. haemolyticus strains, including two isogenic pairs of teicoplanin-susceptible/-resistant strains and two resistant clinical isolates, were used in a morphologic and morphometric electron microscope investigation. Cells from both clinical and laboratory-derived teicoplanin-resistant strains exhibited abnormally roughened, irregular outlines when observed by transmission electron microscopy. However, no significant differences in cell wall thickness resulted from morphometric analysis when the susceptible/resistant cells of the two isogenic pairs were compared. By scanning electron microscopy, an abnormally roughened, blistered surface was associated with teicoplanin-resistant cocci. A certain variability was noted between strains, not clearly related to the resistance level. In freeze-fracture investigations, a higher number per square micrometer of intramembrane particles, more significant in the E than in the P membrane fracture face, was observed in the laboratory-derived resistant clones as compared to susceptible parent strains. Further studies are needed to understand the cause-effect relation between these ultrastructural alterations and staphylococcal resistance to teicoplanin (but not to vancomycin).

SmaI macrorestriction analysis of Italian isolates of erythromycin-resistant Streptococcus pyogenes and correlations with macrolide-resistance phenotypes.

High rates of erythromycin resistance among Streptococcus pyogenes strains have been reported in Italy in the last few years. In this study, 370 erythromycin-resistant (MIC, > or = 1 microg/mL) Italian isolates of this species obtained in 1997-1998 from throat swabs from symptomatic patients were typed by analyzing SmaI macrorestriction fragment patterns by pulsed-field gel electrophoresis (PFGE). Among the typable isolates (n = 341; the genomic DNA of the remaining 29 isolates was not restricted by SmaI), 48 distinct PFGE types were recognized, of which 31 were recorded in only one isolate (one-strain types). Fifty-two percent of typable isolates fell into three type clusters and 75% into six, suggesting that erythromycin-resistant group A streptococci circulating in Italy are polyclonal, but the majority of them probably derives from the spread of a limited number of clones. In parallel experiments, the 370 test strains were characterized for the macrolide resistance phenotype: 80 were assigned to phenotype cMLS, 89 to phenotype iMLS-A, 33 to phenotype iMLS-B, 11 to phenotype iMLS-C, and 157 to phenotype M. There was a close correlation between these phenotypic data and the genotypic results of PFGE analysis, the vast majority of the isolates assigned to individual PFGE classes belonging usually to a single phenotype of macrolide resistance. All of the 29 untypable isolates belonged to the M phenotype. Further correlations were observed with tetracycline resistance.

Evidence for a methicillin-hydrolysing beta-lactamase in Staphylococcus aureus strains with borderline susceptibility to this drug.

A new beta-lactamase that hydrolyses methicillin was found in the membrane fraction of two clinical isolates of Staphylococcus aureus with borderline susceptibility to this drug. 'Methicillinase' activity was detected in renatured sodium dodecyl sulfate polyacrylamide gel electrophoretograms of staphylococcal membrane proteins. The enzyme activity appeared to be inducible and was more easily detected using penicillin G (or methicillin) rather than nitrocefin as substrate. Similar activity was not detected in the membrane fraction of a methicillin-susceptible strain. These results suggest that, in the two borderline susceptible strains, rather than a hyperproduction of the penicillinase a specific methicillin-hydrolysing activity is responsible for the borderline susceptible phenotype.

Cloning and expression of the penicillinase from a borderline methicillin-susceptible Staphylococcus aureus strain in Escherichia coli.

The blaZ gene contained in a single 17.2-kb beta-lactamase plasmid from a borderline methicillin-susceptible Staphylococcus aureus strain (a53) has been cloned in Escherichia coli. A Bluescript II derivative in which the ampicillin resistance gene has been replaced with the chloramphenicol resistance gene was used as a multi-copy vector. One ampicillin-resistant colony was detected among 31 chloramphenicol-resistant transformants selected. This E. coli clone harbored a recombinant plasmid (pAH12) containing two different staphylococcal HindIII inserts (7.0 and 5.3 kb), of which only the former hybridized with a blaZ probe. The clone showed an ampicillin MIC of > 1024 micrograms ml-1, independently of the inoculum size used, and produced large amounts of beta-lactamase, which hydrolyzed nitrocefin and penicillin G but not methicillin of the beta-lactamase substrate, padac. In contrast, S. aureus a53 hydrolyzed all four substrates. The fact that high levels of staphylococcal penicillinase are unable to cause methicillin hydrolysis confirms that penicillinase hyperproduction is unlikely to be the true mechanism responsible for the borderline phenotype. These results also suggest that the two different beta-lactamases (penicillinase and methicillinase) associated with borderline S. aureus strains have a different genetic origin.

Detection of human immunodeficiency virus type 1 transcripts in peripheral blood lymphocytes by the polymerase chain reaction.

A simplified application of the polymerase chain reaction (PCR) to the routine detection of human immunodeficiency virus type 1 (HIV-1) transcripts from peripheral lymphocytes of infected subjects is described. This technique is simpler than previously described assays and was shown to be highly sensitive after ethidium bromide staining of polyacrylamide gel electrophoresis of amplified material. The method can be used for the virologic evaluation of HIV-1-infected subjects, thus allowing early identification of seropositive patients with signs of active infection.

Epidemiology of methicillin-resistant staphylococci in Europe.

Methicillin-resistant staphylococci are mostly resistant not only to all beta-lactams but also to a wide range of other antibiotics, and have emerged as major nosocomial pathogens during the past two decades. Considerable variations in the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) exist between institutions and between geographic areas. In Europe, in general, a north-south gradient is observed, MRSA strains being rare in Scandinavian hospitals (<2%) and far more prevalent in Mediterranean hospitals (>40%). Whether low or high, the rates of MRSA prevalence in European countries have remained approximately the same during the last decade. Recent findings suggest that MRSA might also be emerging as a community-acquired pathogen. The first stage in the emergence of MRSA is its acquisition by methicillin-susceptible S. aureus, and the integration into its chromosome, of the mecA gene, which, together with the other mec genes, is carried on a mobile genetic element, the staphylococcal chromosomal cassette mec (SCCmec). The origin of SCCmec elements as well as the mechanisms of their acquisition remain unknown. Molecular epidemiology studies using different techniques clearly indicate that the massive geographic spread of MRSA results from the dissemination of relatively few highly epidemic clones. Five major lineages (the so-called Iberian, Brazilian, Hungarian, New York/Japan and pediatric pandemic MRSA clones) have been defined. In Europe, the Iberian clone has been reported in several countries; the Brazilian, pediatric and Hungarian clones have also been detected, but less frequently. A unique Italian clone is predominant in Italy. As with S. aureus, coagulase-negative staphylococci (CNS) represent a serious concern in hospital-acquired infections. Despite marked geographic variations, in some areas of Europe high proportions (60-70%) of CNS are methicillin resistant. The formation of biofilm is a key virulence factor of S. epidermidis, the prominent CNS pathogen, which is the most common cause of bacteremia in device-related infections. Another emerging nosocomial pathogen, S. hemolyticus, is characterized by a tendency to develop multiple antibiotic resistances, with a unique predisposition to glycopeptide resistance.

Humoral immune response against hepatitis C virus.

Antibodies are in several instances a reliable marker indicating vigorous immune response against infectious agents and in several viral diseases presence in the blood of specific anti-viral antibodies indicates an effective protection. However, this is not always true. For example, in the case of hepatitis C virus (HCV) an important human pathogen considered the causative agent of the nonA- nonB hepatitis, in spite of an intense antibody response there is no protection against a new infection and in the majority of infected individuals the virus overcomes host defences establishing a persistent infection. Here we describe how the dissection of the humoral immune response against HCV glycoprotein E2 of infected patients was useful for a better comprehension of the virus-host interplay. Cross-reactive antibodies directed against E2 are produced by the HCV-infected patient, but not all of them are protective, and some could even result to be detrimental for the patient. The cross-reactive anti-HCV/E2 humoral antibody response is complex and not necessarily completely beneficial to the host.

Heterogeneity of the humoral anti-HCV/E2 response in persistently infected patients as demonstrated by divergent patterns of inhibition of the binding of anti-HCV/E2 human monoclonal antibodies.

A complete understanding of the molecular features of humoral immune response could be of pivotal importance in the management of persistent viruses as HCV. In this study, 24 HCV-positive samples, characterized by classical virological parameters, are evaluated using a new assay for the quantitation of antibody subpopulations directed against discrete epitopes on surface glycoprotein E2, a key viral protein. The results, besides confirming the usefulness of this new approach, highlight the extreme heterogeneity of anti-HCV/E2 response as far as single epitopes are concerned. The specific epitopes under study are also demonstrated to be widely shared among different genotypes.

Activity of roxithromycin against respiratory pathogens.

The usefulness of macrolides in treating respiratory infections has been established for over thirty years. Currently, a great deal of interest is being focused on roxithromycin, a new semisynthetic derivative of erythromycin which is more stable than erythromycin under acidic conditions and exhibits improved pharmacokinetic properties. In this study, special attention is paid to the results of recent multicenter studies in Italy aimed at evaluating the in vitro activity of roxithromycin versus erythromycin against a wide range of respiratory pathogens. Considering that a high degree of overlap was observed between the roxithromycin-susceptible and the erythromycin-susceptible strains, whereas a significant proportion of erythromycin-resistant strains shifted to the intermediate category with roxithromycin, there appeared to be cross-susceptibility rather than cross-resistance between the two macrolides.

Selection of resistance to glycopeptide antibiotics in staphylococci.

Clinical strains belonging to ten Staphylococcus species were investigated for their abilities to develop single-step resistance in vitro to vancomycin and teicoplanin. Surviving clones were only recovered from strains of three species, namely S. aureus, S. epidermidis, and S. haemolyticus. A similar ratio of grown to plated cells (approximately 1 x 10(-8)) was mostly obtained from strains of S. aureus and S. epidermidis. Higher ratios (1 x 10(-6) to 1 x 10(-7)) were obtained from strains of S. haemolyticus, especially when exposed to teicoplanin. When tested for susceptibility, many survivors exhibited vancomycin and teicoplanin minimum inhibitory concentrations (MICs) below the drug concentration used for in vitro selection, probably due to an inoculum effect in the plating procedure. However, MICs were particularly high in many clones of S. haemolyticus (up to 12.8 microg/ml for vancomycin, and > or = 102.4 microg/ml for teicoplanin).