A Large, Refractory Nosocomial Outbreak of Klebsiella pneumoniae Carbapenemase-Producing Escherichia coli Demonstrates Carbapenemase Gene Outbreaks Involving Sink Sites Require Novel Approaches to Infection Control.

Carbapenem-resistant Enterobacteriaceae (CRE) represent a health threat, but effective control interventions remain unclear. Hospital wastewater sites are increasingly being highlighted as important potential reservoirs. We investigated a large Klebsiella pneumoniae carbapenemase (KPC)-producing Escherichia coli outbreak and wider CRE incidence trends in the Central Manchester University Hospital NHS Foundation Trust (CMFT) (United Kingdom) over 8 years, to determine the impact of infection prevention and control measures. Bacteriology and patient administration data (2009 to 2017) were linked, and a subset of CMFT or regional hospital KPC-producing E. coli isolates (n = 268) were sequenced. Control interventions followed international guidelines and included cohorting, rectal screening (n = 184,539 screens), environmental sampling, enhanced cleaning, and ward closure and plumbing replacement. Segmented regression of time trends for CRE detections was used to evaluate the impact of interventions on CRE incidence. Genomic analysis (n = 268 isolates) identified the spread of a KPC-producing E. coli outbreak clone (strain A, sequence type 216 [ST216]; n = 125) among patients and in the environment, particularly on 2 cardiac wards (wards 3 and 4), despite control measures. ST216 strain A had caused an antecedent outbreak and shared its KPC plasmids with other E. coli lineages and Enterobacteriaceae species. CRE acquisition incidence declined after closure of wards 3 and 4 and plumbing replacement, suggesting an environmental contribution. However, ward 3/ward 4 wastewater sites were rapidly recolonized with CRE and patient CRE acquisitions recurred, albeit at lower rates. Patient relocation and plumbing replacement were associated with control of a clonal KPC-producing E. coli outbreak; however, environmental contamination with CRE and patient CRE acquisitions recurred rapidly following this intervention. The large numbers of cases and the persistence of blaKPC in E. coli, including pathogenic lineages, are of concern.

Regulation of proline-rich protein gene expression by cyclic AMP in primary cultures of hamster parotid glands.

Proline-rich proteins (PRPs) constitute a group of unusual salivary proteins encoded by tissue-specific multigene families which can be dramatically induced (20- to 70-fold) in vivo in rats, mice and hamsters by treatment with the beta-agonist isoproterenol. Addition of dibutyryl cyclic AMP (dbcAMP) or forskolin to hamster parotid gland primary cultures resulted in a large increase (15- to 30-fold) in PRP mRNA levels. The same time-course and levels of induction of PRP mRNA by dbcAMP and isoproterenol were found in primary cultures, indicating that both effectors act through the same mechanism. Induction by isoproterenol, but not by dbcAMP or forskolin, was blocked by the beta-antagonist propranolol. Incorporation of [3H]proline into PRPs was stimulated in primary cultures by all three effectors. The greatest increase in proline incorporation was in the [3H]PRPs recovered in the culture medium of induced cells. These studies demonstrate that cAMP or agents which increase intracellular cAMP levels increase PRP gene expression in primary cultures of parotid glands. Pretreatment of the cells with cycloheximide blocked the induction of PRP mRNAs which indicates that the synthesis of a trans-acting factor may be necessary for transcriptional activation of the PRP genes. alpha-Amylase mRNA, another tissue-specific gene product, was not significantly affected by cycloheximide treatment.

Nebulised beclomethasone dipropionate in preschool asthma.

Twenty nine young children with severe recurrent asthma were given nebulised beclomethasone dipropionate or normal saline in a double blind manner over a six month period. Progress was monitored using diary score cards. Those receiving beclomethasone had lower symptom scores, had more symptom free days, and required less additional treatment with bronchodilator agents. The code needed to be broken more frequently if normal saline was used. Over the study period height and weight increases in the two groups were similar, and no serious side effects were noted.

Seasonal variation and time trends in childhood asthma in England and Wales 1975-81.

In England and Wales hospital admissions for childhood asthma almost trebled over the period 1975-81. This may have reflected a true increase in the incidence of acute asthma, a swing from primary to hospital care, or both. The trend was not due to a change in diagnostic fashion. Monthly admissions showed a pronounced seasonal variation with fewest admissions in winter, rising in spring and early summer to peak in the autumn. A deep admission trough was present in August. The monthly admission profile was very similar throughout England and Wales, suggesting that major "trigger" factors were responsible.