Complicated Carriage with Methicillin-Resistant Staphylococcus aureus: Evaluation of the Effectiveness of Decolonization Regimens Advised in the Dutch National Guideline.

Methicillin-resistant Staphylococcus aureus (MRSA) colonization leads to increased infection rates and mortality. Decolonization treatment has been proven to prevent infection and reduce transmission. As the optimal antimicrobial strategy is yet to be established, different regimens are currently prescribed to patients. This study aimed to evaluate the efficacy of the decolonization treatments recommended by the Dutch guideline. A retrospective multicenter cohort study was conducted in five Dutch hospitals. All patients who visited the outpatient clinic because of complicated MRSA carriage between 2014 and 2018 were included. We obtained data on patient characteristics, clinical and microbiological variables relevant for MRSA decolonization, environmental factors, decolonization regimen, and treatment outcome. The primary outcome was defined as three negative MRSA cultures after treatment completion. Outcomes were stratified for the first-line treatment strategies. A total of 131/224 patients were treated with systemic antibiotic agents. Treatment was successful in 111/131 (85%) patients. The success rate was highest in patients treated with doxycycline-rifampin (32/37; 86%), but the difference from any of the other regimens did not reach statistical significance. There was no difference in the success rate of a 7-day treatment compared to that with 10 to 14 days of treatment (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.39 to 2.53; P = 1.00). Side effects were reported in 27/131 (21%) patients and consisted mainly of mild gastrointestinal complaints. In a multivariable analysis, an immunocompromised status was an independent risk factor for failure at the first treatment attempt (OR, 4.65; 95% CI, 1.25 to 17.25; P = 0.02). The antimicrobial combinations recommended to treat complicated MRSA carriage yielded high success rates. Prolonged treatment did not affect treatment outcome. A randomized trial is needed to resolve whether the most successful regimen in this study (doxycycline plus rifampin) is superior to other combinations.

CT screening for pulmonary pathology in common variable immunodeficiency disorders and the correlation with clinical and immunological parameters.

BACKGROUND: Pulmonary disease is common in patients with common variable immunodeficiency disorders (CVID) and involves infections, chronic airway disease and interstitial lung disease. Chronic pulmonary disease is associated with excess morbidity and early mortality and therefore early detection and monitoring of progression is essential. METHODS AND PURPOSE: Thin slice CT scan and pulmonary function were used to determine the prevalence and spectrum of chronic (pre-clinical) pulmonary disease in adult CVID patients regardless of symptoms. CT Scans were scored for airway abnormalities (AD) and interstitial lung disease (ILD). Other CVID related complications and B and T lymphocyte subsets were analyzed to identify patients at risk for pulmonary disease. RESULTS: Significant pulmonary abnormalities were detected in 24 of the 47 patients (51%) consisting of AD in 30% and ILD in 34% of cases. In only 7 (29%) of these 24 patients pulmonary function test proved abnormal. The presence of AD was correlated to (recurrent) lower respiratory tract infections despite IgG therapy. The presence of ILD was correlated to autoimmune disease and a reduction in the numbers of CD4 + T cells, naïve CD4 + T cells, naïve CD8 + T cells and memory B cells and lower IgG through levels over time. CONCLUSION: Preclinical signs of AD and ILD are common in CVID patients despite Ig therapy and do not correlate to pulmonary function testing. Patients at risk for ILD might be identified by the presence of autoimmunity or a deranged T cell pattern. Larger studies are needed to confirm these findings and to determine thresholds for the T lymphocyte subsets.

Outcome of screening endoscopy in common variable immunodeficiency disorder and X-linked agammaglobulinemia.

Gastrointestinal symptoms are common in patients with common variable immunodeficiency disorders (CVID) and less frequent in X-linked agammaglobulinemia (XLA) although the exact prevalence is not well established. In this study, endoscopic screening was performed in 30 patients with CVID and four patients with XLA. Endoscopic and/or histological abnormalities were detected in 25 of 30 patients with CVID (83 %), regardless of symptoms, and in nine of these patients the results prompted medical treatment. Helicobacter pylori-associated gastritis, adenomatous polyps, and lymphoid hyperplasia were most frequently encountered; no malignancies were detected. Adenomatous polyps were found in two of the four patients with XLA at a relative young age. In conclusion, gastrointestinal pathology is frequent in patients with CVID regardless of symptoms. Patients with XLA seem to be at risk for colorectal adenomas at a young age.

The spectrum of disease manifestations in patients with common variable immunodeficiency disorders and partial antibody deficiency in a university hospital.

BACKGROUND: Common variable immunodeficiency disorders (CVIDs) represents a heterogeneous disease spectrum that includes recurrent infections and complications such as autoimmunity, inflammatory organ disease and an increased risk of cancer. A diagnostic delay is common in CVIDs patients. PURPOSE: To determine the spectrum of clinical manifestations, immunological characteristics, and the time to diagnosis of 61 adult CVIDs and 18 patients with a partial antibody deficiency (SADNI and IgG subclass deficiency). METHODS: A retrospective cohort study was performed in patients who met the ESID/PAGID for CVIDs, IgG subclass deficiency and SADNI. Medical records were reviewed to obtain patient demographics, clinical and laboratory data. RESULTS: Infections were the main presentation of all antibody deficient patients and the number of patients with infections declined during IgG therapy. The development of bronchiectasis continued despite IgG therapy, as well as the development of autoinflammatory conditions. Non-infectious disease complications were present in 30% of CVIDs patients at the time of diagnosis and this increased to 51% during follow up despite IgG therapy. The most common complications were autoimmunity or lymphoproliferative disease. The median time to diagnosis was 10 years and in the patients with non-infectious complications the time to diagnosis was considerably longer when compared to the group of patients without complications (17.6 vs. 10.2 years, p = 0.026). CONCLUSION: In contrast to the partial antibody deficiencies we found a considerable delay in the diagnosis of CVIDs, especially in those patients who were dominated by non-infectious complications, and thus increased awareness would be beneficial. Pulmonary and other complications may continue despite adequate IgG replacement therapy suggesting other causes responsible for these complications.

PCR inhibitors - occurrence, properties and removal.

The polymerase chain reaction (PCR) is increasingly used as the standard method for detection and characterization of microorganisms and genetic markers in a variety of sample types. However, the method is prone to inhibiting substances, which may be present in the analysed sample and which may affect the sensitivity of the assay or even lead to false-negative results. The PCR inhibitors represent a diverse group of substances with different properties and mechanisms of action. Some of them are predominantly found in specific types of samples thus necessitating matrix-specific protocols for preparation of nucleic acids before PCR. A variety of protocols have been developed to remove the PCR inhibitors. This review focuses on the general properties of PCR inhibitors and their occurrence in specific matrices. Strategies for their removal from the sample and for quality control by assessing their influence on the individual PCR test are presented and discussed.

T-cell response to viral antigens in adults and children with common variable immunodeficiency and specific antibody deficiency.

Several T cell abnormalities have been described in common variable immunodeficiency (CVID), a B cell disorder of mainly unknown origin. A subset of CVID patients suffers from frequent reactivations of herpes viruses. We studied T cell function in CVID [and in a subset of paediatric patients with specific antibody deficiency (SAD)] by measuring T cell proliferation and cytokine production in response to herpes virus-antigens in paediatric CVID patients (n=9) and paediatric SAD patients (n=5), in adult CVID patients (n=14) and in healthy controls. Paediatric CVID patients, but not SAD patients, displayed moderately increased CD8+ T cell proliferation in response to cytomegalovirus, human herpes virus type 6B (HHV6-B) and herpes simplex virus compared to controls. CD8+ T cell responses in adult CVID patients tended to be increased in response to cytomegalovirus and herpes simplex virus. In response to stimulation with herpes virus antigens, the proinflammatory cytokines interleukin (IL)-1beta, IL-6, tumour necrosis factor (TNF)-alpha and interferon inducible protein (IP)-10 were produced. Overall, no major differences were detected in cytokine production upon stimulation between patients and controls, although higher IL-10 and IL-12 production was detected in paediatric patients. In conclusion, cellular immunity against herpes virus antigens appears undisturbed in CVID patients, although defects in subpopulations of CVID patients cannot be excluded.

Antibiotic resistance in Salmonella isolates from imported chicken carcasses in Bhutan and from pig carcasses in Vietnam.

The antibiotic resistance in Salmonella isolates from 400 imported chicken carcasses in Bhutan and from 178 pig carcasses in Vietnam were analyzed on a random basis against 14 antimicrobial agents. Among the poultry samples tested, 13% were positive for Salmonella. Salmonella Enteritidis dominated with a prevalence of 80.7%, and 40 of the 42 isolates harbored two or more resistance determinants. For the 178 pigs investigated, 49.4% of the swabs and 34.8% of the lymph nodes were Salmonella positive. The most prevalent serotypes in lymph nodes were Salmonella Derby (50.0%) and Salmonella Typhimurium (27.4%). From the Salmonella isolates from pigs, only 6% were sensitive to the antimicrobial agents tested. The high resistance level of Salmonella isolates from pigs and chicken carcasses to different classes of antimicrobials should be emphasized and encourage a prudent use of these agents in animal farming, especially in pig production.

Analysis of risk factors for Campylobacter species infection in broiler flocks.

We have sampled 146 German broiler flocks at slaughter from May 2004 to April 2005 to determine the prevalence of Campylobacter spp. and to investigate risk factors for the presence of Campylobacter spp. at flock level. Cecal samples were tested in accordance to ISO 10727, and potential risk factors were analyzed using farm- and flock-specific information obtained from questionnaires. Of the flocks tested, 44% were Campylobacter-positive, and most were infected with Campylobacter jejuni. Higher Campylobacter prevalence was found during the months of May to October (52%). Using farm- and flock-specific information obtained from questionnaires, we identified 3 risk factors for Campylobacter colonization. Campylobacter prevalence was significantly higher in flocks from free-range and organic farms, in flocks with a size up to 15,000 birds and with more than 25,000 birds, and in flocks using nipple drinkers with trays. We found no evidence of an effect of slaughter age, time interval between successive flocks, hygiene measures, number of broiler houses on a farm, partial slaughter, source of water supply, and number of farm employees on the Campylobacter infection rate.

Differentiation between fresh and thawed meat by an enzyme profile test.

Exudates from fresh (stored at +4°C) and thawed pork and beef (frozen and stored below -20°C) was assayed by the rapid test kit API-ZYM(TM) to determine enzyme profiles. The test kit consists of 20 wells for different enzyme substrates. Of altogether 1040 results, only few reactions of the enzymes differed in their intensity between frozen and thawed pork or beef. Fresh pork showed a more intensive ß-galactosidase and N-acetyl-ß-glucosaminidase reaction while with fresh beef a more intensive reaction could only be detected for N-acetyl-ß-glucosaminidase. Only N-acetyl-ß-glucosaminidase showed significant differences between fresh and frozen meat in both species (α = 0·01). Considering the indistinct results of the test kit differentiation between frozen and thawed meat, the API-ZYM(TM) test kit is considered not suitable for distinguishing frozen from thawed pork or beef.

[A review of the diagnostic possibilities of illegal drug administration in slaughtered animals and meat inspection]. / Eine Ubersicht zu Diagnosemöglichkeiten unerlaubter Arzneimittelapplikationen bei der Schlachttier- und Fleischuntersuchung.

A review of possible residues of selected antibacterial substances, hormones, beta-agonists, thyreostatics and tranquillizers in meat is given in this paper. Showing their application mode and the few clinical effects and pathological findings, the collection of samples becomes very important. For each group of substances tissues or body-fluids are proposed as samples. With modern analytical detection methods residues in food of animal origin can be demonstrated at levels of micrograms/kg. The detection of the above mentioned substances could be supported by a well-aimed sampling and the illegal use can be diminished.

[The Hazard Analysis Critical Control Point concept for food production]. / Das Hazard Analysis Critical Control Point-Konzept in der Lebensmittelproduktion.

A future standardized EU food controlling concept demands additional efforts in food controlling systems. The Hazard Analysis Critical Control Point (HACCP) concept has already been introduced to the EU food hygiene directive 93/43/EEC as a tool to ensure food safety during production. Primarily, it is a preventive measure for health risks in food. The start of any HACCP application is the collection of data, a risk assessment, the determination of Critical Control Points (CCPs), the specification of critical limits to separate acceptable and unacceptable values for each CCP and finally keeping of records and the verification of the implemented HACCP concept. As shown in the present paper, the application of the HACCP concept should be carried out according to the specific conditions of the individual factory. It is still not known, how small food producers will be able to implement the HACCP concept and how the official food inspection service will adapt to the required inspection procedures.

[Lipopigment in the adipose tissue of slaughtered swine]. / Lipopigment im Fettgewebe von Schlachtschweinen.

After feeding rests of slaughtered poultry together with whey, tapioca and residues of stark production to pigs 70% of the slaughtered pigs were refused by the meat inspection because of yellow fat and yellow hair. The occurrence of bile pigment, carotenoids and synthetic colours could be excluded while acid fast pigments were demonstrated in the fat tissue, liver and skeleton muscle. This could be confirmed by the peroxide number, acid number and the content of malondialdehyde and vitamin E. The results were discussed in the view of meat inspection laws.

[The use of neck skin for microbial process control of fresh poultry meat using the bioluminescence method]. / Untersuchungen zur Eignung der Halshaut für die mikrobiologische Prozesskontrolle von frischem Geflügelfleisch mit dem Biolumineszenzverfahren.

In this study comparative investigations of the total viable counts of bacteria and viable counts of Enterobacteriaceae with the ATP content were carried out on 70 poultry carcasses and neck skins thereof. The results revealed a correlation of total viable counts on the neck skin and on the carcass sample. Therefore the examination on total viable counts of neck skin is able to give results on the respective load of the carcass (coefficient of correlation (r) = 0.85 and coefficient of determination (R2) = 0.71). This only applies, however, to a slaughter technology at which the poultry hangs up site down with the neck skin to the bottom. The results of the ATP investigation expressed in Relative Light Units (RLU) in a bioluminescence method and total viable counts of neck skin samples are correlated (r = 0.85; R2 = 0.72). Lower values for r and R2 were estimated for RLU/Enterobacteriaceae on neck skin (r = 0.64; R2 = 0.41), for RLU/total viable counts on the carcass (r = 0.66; R2 = 0.46) and for RLU/Enterobacteriaceae on the carcass (r = 0.33; R2 = 0.11). To estimate the hygiene status in poultry slaughtery, sampling from the neck skin can replace the sampling on the whole carcass The bioluminescence method is suitable to replace the determination of total viable counts in the context of in-house hygiene supervision. However, this method seemed to be less reliable to predict the Enterobacteriaceae counts.

Quo vadis? - Monitoring Campylobacter in Germany.

Campylobacter is a poorly recognized foodborne pathogen, leading the statistics of bacterially caused human diarrhoea in Europe during the last years. In this review, we present qualitative and quantitative German data obtained in the framework of specific monitoring programs and from routine surveillance. These also comprise recent data on antimicrobial resistances of food isolates. Due to the considerable reduction of in vitro growth capabilities of stressed bacteria, there is a clear discrepancy between the detection limit of Campylobacter by cultivation and its infection potential. Moreover, antimicrobial resistances of Campylobacter isolates established during fattening of livestock are alarming, since they constitute an additional threat to human health. The European Food Safety Authority (EFSA) discusses the establishment of a quantitative limit for Campylobacter contamination of broiler carcasses in order to achieve an appropriate level of protection for consumers. Currently, a considerable amount of German broiler carcasses would not comply with this future criterion. We recommend Campylobacter reduction strategies to be focussed on the prevention of fecal contamination during slaughter. Decontamination is only a sparse option, since the reduction efficiency is low and its success depends on the initial contamination concentration.

Immunoglobulin treatment in primary antibody deficiency.

The primary antibody deficiency syndromes are characterised by recurrent respiratory tract infections and the inability to produce effective immunoglobulin (Ig) responses. The best-known primary antibody deficiencies are common variable immunodeficiency (CVID), X-linked agammaglobulinaemia (XLA), immunoglobulin G (IgG) subclass deficiency, and selective antibody deficiency with normal immunoglobulins (SADNI). Therapy in these patients consists of prophylactic antibiotics and/or Ig replacement therapy. Diagnostic delay remains common owing to limited awareness of the presenting features and may result in increased morbidity and mortality. Replacement therapy with immunoglobulins increases life expectancy and reduces the frequency and severity of infections, but the effect on end-organ damage is still unknown. Both intravenous immunoglobulin (IVIg) and subcutaneous immunoglobulin (SCIg) treatment appear to be safe, with comparable efficacy. A starting dose of 300-400 mg/kg/month in IVIg and 100 mg/week for SCIg is recommended. IgG trough levels should be >5 g/L for patients with agammaglobulinaemia and 3 g/L greater than the initial IgG level for patients with CVID; however, the clinical response should be foremost in choosing the dose and trough level. Infusion-related adverse reactions are generally mild owing to improved manufacturing processes. In this paper, aspects of Ig replacement therapy in primary antibody-deficient patients will be addressed.

Campylobacter spp. in broiler flocks at farm level and the potential for cross-contamination during slaughter.

Screening of broiler flocks for their Campylobacter carriage on farm level and consequently the spread of Campylobacter spp. during slaughtering can help to identify hygiene control points. Therefore, between December 2001 and August 2002 in total 51 broiler flocks from three farms of different geographical regions in Germany were analysed for thermophilic Campylobacter. Campylobacter spp. were isolated from 45% of the broiler flocks examined. Subsequently, 1101 samples were taken from 22 flocks during different stages of processing. Samples were collected from: transport crates before and after cleaning/disinfection, evisceration, post-scalded and post-chilled carcasses and endproducts. Additionally, 45 selected Campylobacter isolates of droppings were genotyped by pulsed-field gel electrophoresis (PFGE). Campylobacter carriage of flocks showed seasonal variation, with the highest contamination rate during the period of June to August. No evidence was found for a horizontal transmission from one broiler flock to the next via a persistent house-contamination. In each positive flock, one to three different genotypes were found. One or two clones dominated isolations obtained from the farm level. The fact that in different flocks indistinguishable isolates of clonal origin were detected during the same rearing period suggested a transmission between the broiler flocks or an intermittent common external source. In one case, isolates of clonal origin were detected in various farms during different rearing periods. Sampling during processing confirmed that the entrance of a positive flock resulted in contamination of the abattoir environment. Campylobacter spp. were isolated from all sampling stages along the processing line, with a percentage of 91.1-100 of isolates at different stages of slaughtering.