[The history of antibiotics]. / Historien om antibiotika.

The development of chemical compounds for the treatment of infectious diseases may be divided into three phases: a) the discovery in the 1600s in South America of alkaloid extracts from the bark of the cinchona tree and from the dried root of the ipecacuanha bush, which proved effective against, respectively, malaria (quinine) and amoebic dysentery (emetine); b) the development of synthetic drugs, which mostly took place in Germany, starting with Paul Ehrlich's (1854-1915) discovery of salvarsan (1909), and crowned with Gerhard Domagk's (1895-1964) discovery of the sulfonamides (1930s); and c) the discovery of antibiotics. The prime example of the latter is the development of penicillin in the late 1920s following a discovery by a solitary research scientist who never worked in a team and never as part of a research programme. It took another ten years or so before drug-quality penicillin was produced, with research now dependent on being conducted in large collaborative teams, frequently between universities and wealthy industrial companies. The search for new antibiotics began in earnest in the latter half of the 1940s and was mostly based on soil microorganisms. Many new antibiotics were discovered in this period, which may be termed «the golden age of antibiotics¼. Over the past three decades, the development of new antibiotics has largely stalled, while antibiotic resistance has increased. This situation may require new strategies for the treatment of infectious diseases.

Chromosomal integration of the extended-spectrum beta-lactamase gene blaCTX-M-15 in Salmonella enterica serotype Concord isolates from internationally adopted children.

We report the emergence of Salmonella enterica isolates of serotype Concord (and its monophasic variant 6,7:l,v:-) producing the extended-spectrum beta-lactamases (ESBLs) SHV-12 and CTX-M-15 in France and Norway between 2001 and 2006 (43 in France and 26 in Norway). The majority of these isolates were from adopted children from Ethiopia, most of whom were healthy carriers. Several symptomatic secondary cases were found in the adoptive families and health care facilities in France. Serotype Concord isolates collected before 2003 produced SHV-12 encoded on a 340-kb conjugative plasmid of replicon IncI1. Isolates collected after 2003 produced CTX-M-15. We detected two conjugative plasmids carrying bla(CTX-M-15). One plasmid, approximately 300 kb in size, was positive for the IncHI2 replicon and the plasmid-mediated quinolone resistance gene qnrA1. The other plasmid, from one of the earliest CTX-M-15-producing isolates collected, was a fusion plasmid with IncY and IncA/C(2) replicons and was 200 kb in size. However, we showed, using Southern hybridization of I-CeuI-digested chromosomal DNA and S1 nuclease analysis of plasmid DNA, that most isolates had a bla(CTX-M-15) gene located on chromosomal DNA. Analysis of the flanking regions of the chromosomally located bla(CTX-M-15) gene by cloning revealed an ISEcp1 truncated by an intact IS26 upstream from the bla(CTX-M-15) gene and a truncated orf477 gene downstream from bla(CTX-M-15). We found regions beyond the IS26 and the orf477 genes that were derived from IncA/C(2) plasmids, suggesting the chromosomal integration of part of the bla(CTX-M-15)-carrying IncY and IncA/C(2) fusion plasmid from early CTX-M-15-producing isolates.

Outbreak of haemolytic uraemic syndrome in Norway caused by stx2-positive Escherichia coli O103:H25 traced to cured mutton sausages.

BACKGROUND: On 20-21 February 2006, six cases of diarrhoea-associated haemolytic uraemic syndrome (HUS) were reported by paediatricians to the Norwegian Institute of Public Health. We initiated an investigation to identify the etiologic agent and determine the source of the outbreak in order to implement control measures. METHODS: A case was defined as a child with diarrhoea-associated HUS or any person with an infection with the outbreak strain of E. coli O103 (defined by the multi-locus variable number tandem repeats analysis (MLVA) profile) both with illness onset after January 1st 2006 in Norway. After initial hypotheses-generating interviews, we performed a case-control study with the first fifteen cases and three controls for each case matched by age, sex and municipality. Suspected food items were sampled, and any E. coli O103 strains were typed by MLVA. RESULTS: Between 20 February and 6 April 2006, 17 cases were identified, of which 10 children developed HUS, including one fatal case. After pilot interviews, a matched case-control study was performed indicating an association between a traditional cured sausage (odds ratio 19.4 (95% CI: 2.4-156)) and STEC infection. E. coli O103:H25 identical to the outbreak strain defined by MLVA profile was found in the product and traced back to contaminated mutton. CONCLUSION: We report an outbreak caused by a rare STEC variant (O103:H25, stx2-positive). More than half of the diagnosed patients developed HUS, indicating that the causative organism is particularly virulent. Small ruminants continue to be important reservoirs for human-pathogen STEC. Improved slaughtering hygiene and good manufacturing practices for cured sausage products are needed to minimise the possibility of STEC surviving through the entire sausage production process.

Outbreak of Salmonella Thompson infections linked to imported rucola lettuce.

On November 15, 2004, a cluster of three cases of Salmonella Thompson infection was registered by the Norwegian reference laboratory. In the following days further cases occurred, prompting a case-control study among the first 13 cases and 26 matched controls. By December 31, 21 cases had been reported, with the first onset on October 24. Consumption of rucola lettuce (Eruca sativa, also known as rocket salad or arugula) (OR 8,8 [1,2-infinity]) and mixed salad (OR 5,0 [1,0-infinity]) was associated with illness. On November 26, Swedish authorities notified the finding of Salmonella Thompson in rucola lettuce through the EU Rapid Alert System for Food and Feed. Later, several countries reported finding this and other Salmonella serovars and Campylobacter in rucola produced in Italy. In response to our alert through the international Enter-net surveillance network, Sweden and England also reported an increase of cases. Salmonella Thompson isolates from products and patients from several countries showed high similarity by pulsed-field gel electrophoresis, but some isolates showed significant differences. We think that the outbreak in Norway reflected a larger international outbreak caused by rucola imported from one Italian producer. Findings of other pathogens indicate a massive contamination, possibly caused by irrigation with nonpotable water. Rapid international information exchange is invaluable when investigating outbreaks caused by internationally marketed products.

Clonal reconquest of antibiotic-susceptible Salmonella enterica serotype Typhi in Son La Province, Vietnam.

In the last three decades, high rates of resistance to common first-line antimicrobial agents have been reported in Salmonella enterica serotype Typhi (Typhi), the causative organism of typhoid fever (TF), in many regions of the world, especially in South East Asia. Analysis of Typhi strains isolated from outbreaks and sporadic cases of TF in Son La province, northwest Vietnam, in 2002 revealed that 94.5% (85/90) of the isolates were fully susceptible to amoxicillin, chloramphenicol, cotrimoxazole, tetracycline, and nalidixic acid. There was a clear decline in the occurrence of multi-drug resistant (MDR) Typhi isolates collected in this province in 2002 (4.4%) compared with the period 1995-1999 in the same province (30.8-100%). By using molecular (IS200 profiling, PstI-ribotyping, XbaI-pulsed-field gel electrophoresis, and haplotyping) and phage-typing methods, we showed that the Typhi isolates from Son La province in 2002 were genetically related; however, they were unrelated to the previous MDR clones established in Vietnam.

Octaplex PCR and fluorescence-based capillary electrophoresis for identification of human diarrheagenic Escherichia coli and Shigella spp.

A multiplex PCR assay, amplifying seven specific virulence genes and one internal control gene in a single reaction, was developed to identify the five main pathotypes of diarrheagenic Escherichia coli and Shigella spp. The virulence genes selected for each category were Stx1, Stx2, and eaeA for enterohemorrhagic E. coli (EHEC), eaeA for enteropathogenic E. coli (EPEC), STIb and LTI for enterotoxigenic E. coli (ETEC), ipaH for enteroinvasive E. coli (EIEC) and Shigella spp., and aggR for enteroaggregative E. coli (EAEC). Each forward primer was labelled with a fluorochrome and the PCR products were separated by multicolour capillary electrophoresis on an ABI PRISM310 Genetic Analyzer (Applied Biosystems). If present, several gene variants of each virulence gene were identified. The internal control gene rrs, encoding 16S rRNA, was amplified in all 110 clinical strains analyzed. Virulence genes were demonstrated in 103 (94%) of these strains. In the majority of the cases (98/103, 95%), classification obtained by the novel multiplex PCR assay was in agreement with that previously determined by phenotypic assays combined with other molecular genetic approaches. Numerous multiplex PCR assays have been published, but only a few of them detect all five E. coli pathotypes within a single reaction, and none of them has used multicolour capillary electrophoresis to separate the PCR products. The octaplex PCR assay followed by capillary electrophoresis presented in the present paper provides a simple, reliable, and rapid procedure that in a single reaction identifies the five main pathotypes of E. coli, and Shigella spp. This assay will replace the previous molecular genetic methods used in our laboratory and work as an important supplement to the more time-consuming phenotypic assays.

Pseudomonas aeruginosa contamination of mouth swabs during production causing a major outbreak.

BACKGROUND: In 2002 we investigated an outbreak comprising 231 patients in Norway, caused by Pseudomonas aeruginosa and linked to the use of contaminated mouth swabs called Dent-O-Sept. Here we describe the extent of contamination of the swabs, and identify critical points in the production process that made the contamination possible, in order to prevent future outbreaks. METHODS: Environmental investigation with microbiological examination of production, ingredients and product, molecular typing of bacteria and a system audit of production. RESULTS: Of the 1565 swabs examined from 149 different production batches the outbreak strain of P. aeruginosa was detected in 76 swabs from 12 batches produced in 2001 and 2002. In total more than 250 swabs were contaminated with one or more microbial species. P. aeruginosa was detected from different spots along the production line. The audit revealed serious breeches of production regulations. Health care institutions reported non-proper use of the swabs and weaknesses in their purchasing systems. CONCLUSION: Biofilm formation in the wet part of the production is the most plausible explanation for the continuous contamination of the swabs with P. aeruginosa over a period of at least 30 weeks. When not abiding to production regulations fatal consequences for the users may ensue. For the most vulnerable patient groups only documented quality-controlled, high-level disinfected products and items should be used in the oropharynx.

[An outbreak of Yersinia enterocolitica O:9-infection]. / Et utbrudd av Yersinia enterocolitica O:9-infeksjon.

BACKGROUND: Yersiniosis is a zoonosis that is transmitted from pigs to humans. In January 2006 more cases of Yersinia enterocolitica enterocolitis than expected were reported in Norway. The fact that the isolates belonged to the O:9 serogroup, which is rare in Norway, and the geographical and temporal clustering of the cases, pointed to an outbreak. We have conducted a retrospective study of 11 patients who were diagnosed during this outbreak. MATERIAL AND METHODS: The material is based upon applicants' information, patient journals and a questionnaire. In order to disclose the source of infection, a case-control survey was performed. RESULTS: Nine of the 11 patients had enterocolitis and two had septicaemia, both of whom died following a few days of treatment. One patient presented with pseudo- appendicitis while another developed monoarthritis, which persisted for more than three months after the debut of symptoms Treatment with antibiotics was offered in six cases. The case-control analysis indicated that brawn was the probable source of infection. INTERPRETATION: This is the first reported Norwegian outbreak of Y. enterocolitica O:9 disease. The incubation time, disease duration and frequency of intestinal and immunological complications corresponds with previously published data. The frequency of septicaemia exceeds several previously reported outbreaks and retrospective studies of sporadic cases.

Lack of agreement between biochemical and genetic identification of Aeromonas spp.

Biochemical and genetic identification by RFLP (restriction fragment length polymorphism) of the PCR-amplified 16S r-RNA sequence were compared for a selection of 171 clinical and environmental isolates of Aeromonas spp. The investigation revealed large differences between the two methods. The species phenotypic identification scheme and the genetic technique applied to the environmental strains gave divergent results for 96% of the strains tested. There was 46% discrepancy between the two methods for the clinical isolates. The distribution of species differed between clinical and environmental isolates. A. hydrophila, A. caviae, A. jandaei and A. veronii dominated the clinical material (81% of isolates by RFLP), whilst only 21% of the environmental isolates belonged to those four species. From the environmental group A. salmonicida, A. bestiarum, A. sobria, A. media, and A. encheleia contributed 72% of the strains tested. The poor parity between the biochemical and the genetic identification of the environmental isolates, and to a lesser extent for the clinical isolates, underlines the fact that our current biochemical methods cannot adequately differentiate Aeromonas spp. This work also shows that the biochemical schemes derived from clinical isolates are incomplete for the identification of environmental strains.

Genetic variability among isolates of Listeria monocytogenes from food products, clinical samples and processing environments, estimated by RAPD typing.

RAPD analysis with four primers was used to examine the genetic relationship among 432 strains of Listeria monocytogenes isolated from clinical and veterinarian cases of listeriosis, dairy, vegetable, meat- and fish-based food items, environmental samples and samples collected from one transport terminal, one poultry-processing company and four Atlantic salmon-processing plants. The purpose of the study was to determine whether clinical isolates belonged to a specific genetic group, whether links could be made between food groups and clinical cases and whether specific genetic groups were associated with specific food products or processing units. There was great genetic variability among the isolates, which produced a total of 141 RAPD composites based on the RAPD analysis with four primers. The RAPD composites divided in two major clusters and clinical isolates were evenly distributed in both of them. None of the isolates from food products had the same RAPD composite as isolates from human patients, thus, no particular food commodity could be linked to clinical cases. Each food-processing environment was contaminated with more than one RAPD composite and the genetic variability found within each company was, in most cases, of approximately the same magnitude as the variability found when considering all the samples. In each plant, one or a few types persisted over time, indicating the presence of an established in-house flora. Our results indicate that most of the analysed cases of listeriosis were sporadic and, further, that these cases cannot be traced to a few specific food sources. We also found that no particular RAPD composite was better suited for survival in specific food types or food-processing environments, indicating that although differences may be found in virulence properties of individual strains, all L. monocytogenes must be treated as potentially harmful.

[Are domestic Cryptosporidium and Giardia infections in Norway underdiagnosed?]. / Underdiagnostiseres innenlandssmittede Cryptosporidium- og Giardia-infeksjoner i Norge?

BACKGROUND: Cryptosporidium and Giardia are recognised as common causes of waterborne disease in several countries. In order to describe investigative practices for these protozoan parasites in Norway, we surveyed medical microbiology laboratories nationwide for faecal screening policies and methods used for detection of Cryptosporidium and Giardia. MATERIAL AND METHODS: All medical microbiology laboratories in Norway received questionnaires on laboratory methods, indications for screening, and numbers of samples investigated over the 1998-2002 period. RESULTS: Of the 22 laboratories that receive faecal samples, 17 had established diagnostic routines for Giardia detection, 14 for Cryptosporidium. Examination for Giardia cysts was standard procedure in all 17 laboratories, mainly in specimens from immigrants and travellers returning from abroad. Examination for Cryptosporidium was, on the other hand, infrequent. Ten of the 14 laboratories reported less than 10 examinations per year. Giardia was frequently detected, with 1 to 6% positive samples in the various laboratories. Cryptosporidium was seldom detected; all laboratories reported only 0-1 positive sample per year. INTERPRETATION: While laboratories frequently screen faecal samples for Giardia, screening for Cryptosporidium is rare. Little is known about the public health significance of domestic infections with these parasites in Norway; further investigation is needed in order to estimate the burden of disease they cause and to implement control measures if required.

Tesofensine, a novel triple monoamine re-uptake inhibitor with anti-obesity effects: dopamine transporter occupancy as measured by PET.

Tesofensine (TE) is a novel triple monoamine re-uptake inhibitor inducing a potent inhibition of the re-uptake process in the synaptic cleft of the neurotransmitters dopamine, norepinephrine, and serotonin. In recent preclinical and clinical evaluations TE showed a robust anti-obesity effect, but the specific mechanism of this triple monoamine re-uptake inhibitor still needs to be further elucidated. This positron emission tomography (PET) study, using [¹¹C]ßCIT-FE, aimed to assess the degree of the dopamine transporter (DAT) occupancy, at constant TE plasma levels, following different oral, multiple doses of TE during totally 8-12 days. In addition, the relationships between DAT occupancy and TE plasma concentrations, or doses, were investigated to enable assessment of DAT occupancies in subsequent clinical trials. The results demonstrated that TE induced a dose-dependent blockade of DAT following multiple doses of 0.125-1 mg TE at anticipated steady-state conditions. The mean striatal DAT occupancy varied dose-dependently between 18% and 77%. A sigmoid E(max) model well described the relationship between striatal DAT occupancy and TE plasma concentrations or doses. It was estimated that the maximum achievable DAT occupancy was about 80% and that half of this effect was accomplished by approximately 0.25 mg TE and a plasma drug concentration of 4 ng/ml. The results indicated an important mechanism of action of TE on DAT. Further, these results suggest that the previously reported dose-dependent weight loss, in TE treated subjects, was in part mediated by an up-regulation of dopaminergic pathways due to enhanced amounts of synaptic dopamine after blockade of DAT.

Anti-hypertensive treatment preserves appetite suppression while preventing cardiovascular adverse effects of tesofensine in rats.

OBJECTIVE: Tesofensine is a novel triple monoamine reuptake inhibitor which is in development for the treatment of obesity. Preclinical and clinical data suggest that appetite suppression is an important mechanism by which tesofensine exerts its robust weight reducing effect. Notably, the strong hypophagic response to tesofensine treatment is demonstrated to be linked to central stimulation of noradrenergic and dopaminergic neurotransmission. The sympathomimetic mode of action of tesofensine may also associate with the elevated heart rate and blood pressure observed in clinical settings, and we therefore sought experimentally to address this issue. DESIGN AND METHODS: The anorexigenic and cardiovascular effects of tesofensine were studied simultaneously in telemetrized conscious rats in a combined real-time food intake and cardiovascular telemetry monitoring system. RESULTS: Acute administration of tesofensine caused a dose-dependent hypophagic effect as well as increased heart rate and blood pressure. Interestingly, combined treatment with metoprolol (b1 adrenoceptor blocker, 10-20 mg/kg, p.o.) fully prevented the cardiovascular sympathetic effects of tesofensine while leaving the robust inhibitory efficacy on food intake unaffected. Similarly, the angiotensin AT1 receptor antagonist telmisartan (1.0-3.0 mg/kg, p.o.) did not interfere with the anti-obesity effects of tesofensine, however, telmisartan only partially reversed the increase in systolic blood pressure and had no effect on the elevated heart rate induced by tesofensine. CONCLUSION: These data suggests that tesofensine causes elevations in heart rate and blood pressure by increasing sympathetic activity, and that different adrenoceptor subtypes may be responsible for the anti-obesity and cardiovascular effects of tesofensine.