Clostridioides difficile-associated diarrhea in surgical service patients in Mexico. / Diarrea asociada a Clostridioides difficile en pacientes de servicios quirúrgicos en México.

INTRODUCTION: Clostridioides difficile is the first cause of healthcare-associated diarrhea in developed countries. In recent years the incidence of C. difficile infection (CDI) has increased worldwide. There is not much information on the topic in Mexico, and little is known about the risk factors for the infection in patients that are hospitalized in surgical services. MATERIALS AND METHODS: A case-control study was conducted that compared the epidemiologic findings and risk factors between surgical patients with PCR-confirmed CDI, surgical patients with diarrhea and a negative PCR test, and surgical patients with no diarrhea. The statistical analysis was carried out using the SPSS version 22.0 program. RESULTS: The majority of the surgical patients with CDI belonged to the areas of neurosurgery, cardiac surgery, orthopedics, and general surgery. A total of 53% of the CDI cases were associated with the hypervirulent CD NAP1/027 strain. The presence of mucus in stools (OR: 1.5, P=.001), fever (OR: 1.4, P=.011), leukocytes in stools (OR: 3.2, P<.001), hospitalization within the past 12weeks (OR: 2.0, P<.001), antibiotic use (OR: 1.3, P=.023), and ceftriaxone use (OR: 1.4, P=.01) were independent risk factors for the development of CDI. CONCLUSIONS: C. difficile-induced diarrhea in the surgical services is frequent at the Hospital Civil de Guadalajara "Fray Antonio Alcalde".

Consensus on the prevention, diagnosis, and treatment of Clostridium difficile infection. / Consenso sobre prevención, diagnóstico y tratamiento de la infección por Clostridium difficile.

In recent decades, Clostridium difficile infection (CDI) has become a worldwide health problem. Mexico is no exception, and therefore the Asociación Mexicana de Gastroenterología brought together a multidisciplinary group (gastroenterologists, endoscopists, internists, infectious disease specialists, and microbiologists) to carry out the "Consensus on the prevention, diagnosis, and treatment of Clostridium difficile infection", establishing useful recommendations (in relation to the adult population) for the medical community. Said recommendations are presented herein. Among them, it was recognized that CDI should be suspected in subjects with diarrhea that have a history of antibiotic and/or immunosuppressant use, but that it can also be a community-acquired infection. A 2-step diagnostic algorithm was proposed, in which a highly sensitive test, such as glutamate dehydrogenase (GDH), is first utilized, and if positive, confirmed by the detection of toxins through immunoassay or nucleic acid detection tests. Another recommendation was that CDI based on clinical evaluation be categorized as mild-moderate, severe, and complicated severe, given that such a classification enables better therapeutic decisions to be made. In mild-moderate CDI, oral vancomycin is the medication of choice, and metronidazole is recommended as an alternative treatment. In addition, fecal microbiota transplantation was recognized as an efficacious option in patients with recurrence or in the more severe cases of infection, and surgery should be reserved for patients with severe colitis (toxic megacolon), in whom all medical treatment has failed.

Virulence Factors of Clostridioides (Clostridium) difficile Linked to Recurrent Infections.

From 20 to 30% of Clostridioides (Clostridium) difficile infection (CDI), patients might develop recurrence of the infection (RCDI) and, after the first recurrence, the risk of further episodes increases up to 60%. Several bacterial virulence factors have been associated with RCDI, including the elevated production of toxins A and B, the presence of a binary toxin CDT, and mutations in the negative regulator of toxin expression, tcdC. Additional factors have shown to regulate toxin production and virulence in C. difficile in RCDI, including the accessory-gene regulator agr, which acts as a positive switch for toxin transcription. Furthermore, adhesion and motility-associated factors, such as Cwp84, SlpA, and flagella, have shown to increase the adhesion efficiency to host epithelia, cell internalization, and the formation of biofilm. Finally, biofilm confers to C. difficile protection from antibiotics and acts as a reservoir for spores that allow the persistence of the infection in the host. In this review, we describe the key virulence factors of C. difficile that have been associated with recurrent infections.

Emerging of ptxP3 lineage in Bordetella pertussis strains circulating in a population in northeastern Mexico.

We determined the molecular epidemiology of Bordetella pertussis isolates to evaluate its potential impact on pertussis reemergence in a population of Mexico. Symptomatic and asymptomatic cases were included. Pertussis infection was confirmed by culture and real-time polymerase chain reaction (PCR). Selected B. pertussis isolates were further analysed; i.e. clonality was analysed by pulsed-field gel electrophoresis (PFGE) and ptxP-ptxA, prn, fim2 and fim3 typing was performed by PCR and sequencing. Out of 11 864 analysed samples, 687 (5.8%) were positive for pertussis, with 244 (36%) confirmed by both culture and PCR whereas 115 (17%) were positive only by culture and 328 (48%) were positive only by PCR. One predominant clone (clone A, n = 62/113; 55%) and three major subtypes (A1, A2 and A3) were identified by PFGE. All 113 selected isolates had the allelic combination ptxP3-ptxA1. The predominant clone A and the three major subtypes (A1, A2 and A3) corresponded to the emerging genotypes ptxP3-ptxA1-prn2-fim2-1-fim3-2 and ptxP3-ptxA1-prn2-fim2-1-fim3-1. In conclusion, the presence of an endemic clone and three predominant subtypes belonging to the genotypes ptxP3-ptxA1-prn2-fim2-1-fim3-2 and ptxP3-ptxA1-prn2-fim2-1-fim3-1 were detected. This finding supports the global spread/expansion reported for these outbreaks associated genotypes.

The fourth Mexican consensus on Helicobacter pylori. / IV consenso mexicano sobre Helicobacter pylori.

Important advances have been made since the last Mexican consensus on the diagnosis and treatment of Helicobacter pylori (H. pylori) infection was published in 2007. Therefore, the Asociación Mexicana de Gastroenterología summoned 20 experts to produce "The Fourth Mexican Consensus on Helicobacter pylori". From February to June 2017, 4 working groups were organized, a literature review was performed, and 3 voting rounds were carried out, resulting in the formulation of 32 statements for discussion and consensus. From the ensuing recommendations, it was striking that Mexico is a country with an intermediate-to-low risk for gastric cancer, despite having a high prevalence of H. pylori infection. It was also corroborated that peptic ulcer disease, premalignant lesions, and histories of gastric cancer and mucosa-associated lymphoid tissue lymphoma should be considered clear indications for eradication. The relation of H. pylori to dyspeptic symptoms continues to be controversial. Eradication triple therapy with amoxicillin, clarithromycin, and a proton pump inhibitor should no longer be considered first-line treatment, with the following 2 options proposed to take its place: quadruple therapy with bismuth (proton pump inhibitor, bismuth subcitrate, tetracycline, and metronidazole) and quadruple therapy without bismuth (proton pump inhibitor, amoxicillin, clarithromycin, and metronidazole). The need for antimicrobial sensitivity testing when 2 eradication treatments have failed was also established. Finally, the promotion of educational campaigns on the diagnosis and treatment of H. pylori for both primary care physicians and the general population were proposed.

Draft Genome Sequence of a Hypermucoviscous Extended-Spectrum-ß-Lactamase-Producing Klebsiella quasipneumoniae subsp. similipneumoniae Clinical Isolate.

A clinical isolate of extended-spectrum-ß-lactamase-producing Klebsiella quasipneumoniae subsp. similipneumoniae 06-219 with hypermucoviscosity phenotypes obtained from a urine culture of an adult patient was used for whole-genome sequencing. Here, we report the draft genome sequences of this strain, consisting of 53 contigs with an ~5.6-Mb genome size and an average G+C content of 57.36%. The annotation revealed 6,622 coding DNA sequences and 77 tRNA genes.

Antibacterial and antimycobacterial lignans and flavonoids from Larrea tridentata.

Three lignans and four flavonoids were isolated and characterized from Larrea tridentata and compounds were tested against 16 bacterial species/strains. Results showed that: dihydroguaiaretic acid (1) had activity towards methicillin resistant (MR) Staphylococcus aureus (minimum inhibitory concentration (MIC) 50 µg/mL) and multidrug-resistant (MDR) strains of Mycobacterium tuberculosis (MIC 12.5-50 µg/mL); 4-epi-larreatricin (2) was active against Enterobacter cloacae (MIC 12.5 µg/mL), as well as sensitive (MIC 50 µg/mL) and MDR strains of M. tuberculosis (MIC 25 µg/mL). 3'-Demethoxy-6-O-demethylisoguaiacin (3) displayed activity against sensitive and resistant S. aureus (MIC 25 µg/mL), Enterococcus faecalis (MIC 12.5 µg/mL), Escherichia coli (MIC 50 µg/mL), E. cloacae (MIC 12.5 µg/mL) and MDR strains of M. tuberculosis (MIC 12.5 µg/mL). 5,4'-Dihydroxy-3,7,8,3'-tetramethoxyflavone (4) and 5,4'-dihydroxy-3,7,8-trimethoxyflavone (5) were active against M. tuberculosis MDR strains having MIC values of 25 and 25-50 µg/mL, respectively, while 5,4'-dihydroxy-7-methoxyflavone (6) was active against S. aureus (MIC 50 µg/mL) and E. faecalis (MIC 50 µg/mL). We concluded that lignan 3 is the main compound responsible for the antibacterial activity of L. tridentata. Lignans 1 and 2 as well as flavonoid 6 contribute with some degree of antibacterial activity. On the other hand, compounds 1, 2, 3, 4 and 5 contributed to the antimycobacterial activity found in L. tridentata.

Prevalence of foodborne pathogens in grilled chicken from street vendors and retail outlets in Reynosa, Tamaulipas, Mexico.

We analyzed a total of 70 grilled chicken samples bought randomly from street vendors and retail outlets in the city of Reynosa, Mexico, to determine the prevalence of Escherichia coli (Shiga toxin producing and enterotoxin producing), Salmonella spp., Staphylococcus aureus, Listeria spp., and Campylobacter spp. using microbiological methods and PCR detection of bacterial sequences. Of the 70 samples, 27 (38.5%) were from retail outlets and 43 (61.4%) from street vendors. All specimens were negative by both microbiological and molecular methods for Listeria monocytogenes, Shiga toxin 2 of Shiga toxin-producing E. coli, lt of enterotoxin-producing E. coli, and st enterotoxin, and all were negative for Salmonella spp. and Campylobacter jejuni by PCR. Of the samples studied, 49 (70%) had undetectable levels of the foodborne pathogens studied with the methods used. In the remaining 21 (30%) specimens, at least one pathogen was isolated or detected, with E. coli being the pathogen most frequently isolated and with two samples bearing the hlyA gene. We found no statistical difference in bacterial prevalence between retail and street vendor samples. The presence of pathogens in grilled chicken is an important public health risk because of the great demand for and daily consumption of this product in this region.

[Epidemiology and clinical characteristics of ulcerative colitis in north-eastern Mexico]. / Epidemiología y características clínicas de la colitis ulcerosa crónica idiopática en el noreste de México.

BACKGROUND: Inflammatory Bowel Disease (IBD) compromises two entities: Ulcerative Colitis (UC) and Crohn Disease (CD). The incidence and prevalence vary widely in relation to ethnicity and demographic localization. Historically it has been considered a rare disease in Mexico. OBJECTIVE: To determine the frequency of new UC cases and their clinical characteristics in a referral hospital of North-Eastern Mexico. METHODS: An epidemiological, descriptive and retrospective study was made which included newly diagnosed patients with UC in a five years period. RESULTS: The adjusted rate of patients diagnosed with UC to the number of admissions for year was 2.3, 2.6, 3.0, 3.6 and 4.1/1000 admissions between 2004 and 2008. The rate of newly diagnosed patients with UC has doubled in the year 2008 compared with the year 2004 (p < 0.05). Fifty five percent of the patients showed mild disease, 30% showed moderate disease and 15% showed severe disease. Fifty percent of the patients had pancolitis, left sided colitis was present in 21% and 29% of the patients just had proctitis. Other clinical aspects of UC corresponded to those previously described. CONCLUSION: The frequency of new patients diagnosed with UC has significantly increased in this tertiary-care referral hospital for the last five years.

Genetic risk factors for inflammatory bowel disease in a North-eastern Mexican population.

The purpose of this study was to assess the role of Helicobacter pylori and several genetic polymorphisms in relation to inflammatory bowel disease (IBD). We studied 44 unrelated patients with IBD and 75 subjects with no history of IBD as controls. Using pyrosequencing technology, we identified gene polymorphisms in IL-10, TNF-A, ILB-31, and TLR4. H. pylori status was determined by serology. Individuals homozygous for IL10-592 A or IL10-1082 A genotypes show significantly lower occurrence of IBD (P=0.03 and P<0.01, respectively). Individuals heterozygous at IL10-1082 have significantly increased occurrence of IBD, both ulcerative colitis and Crohn's disease (P<0.01). There was no difference in the prevalence of H. pylori infection between cases and controls. This study provides evidence that variation in IL10 is correlated with IBD occurrence in this Mexican population.

A pyrosequencing method for molecular monitoring of regions in the inhA, ahpC and rpoB genes of Mycobacterium tuberculosis.

In this study, a pyrosequencing method for monitoring two genes related to isoniazid (INH)-resistance and a region of the rpoB gene linked to rifampin (RMP)-resistance in Mycobacterium tuberculosis was developed and evaluated. Specifically, a 20-base pair (bp) region of inhA (from -24 to -4), a 35-bp region of ahpC (from -39 to -4), and a 57-bp region of rpoB (from codon 515 to 533) were analysed by pyrosequencing. For the development of the method, selected non-consecutive clinical isolates of M. tuberculosis were analysed, including: 25 isolates susceptible to both INH and RMP, 18 RMP-monoresistant isolates, 17 INH-monoresistant isolates, and 15 multidrug-resistant strains. Our pyrosequencing methodology was further evaluated using 96 M. tuberculosis isolates. Mutations in ahpC were found to be associated with INH resistance (p <0.05). By setting any mutation in ahpC as a marker of resistance, the specificity and the positive predictive value (PPV) were 100%. Similarly, any mutation in the rpoB gene was associated with a RMP resistance phenotype (p <0.01). Using any mutation in rpoB as a marker of RMP resistance, the sensitivity of this assay was 73% and the specificity and PPV were 100%. The use of this pyrosequencing method to analyse the ahpC and rpoB genes allowed us to detect INH- and/or RMP-resistant isolates. Furthermore, this method represents an opportunity to expedite the description of novel mutations related to drug resistance.

Staphylococcal cassette chromosome mec (SCC mec) in methicillin-resistant coagulase-negative staphylococci. A review and the experience in a tertiary-care setting.

Coagulase-negative staphylococci (CNS) are increasingly recognized to cause clinically significant infections, with S. epidermidis often cited as the third most common cause of nosocomial sepsis. Among CNS, there is a high prevalence of methicillin resistance associated with staphylococcal cassette chromosome (SCCmec) elements. Although identical SCCmec types can exist in S. aureus and CNS, some novel classes of SCCmec may be unique to CNS. Differences in the accuracy of identification of CNS species and use of non-standardized methods for the detection of methicillin resistance have led to confusing data in the literature. In addition to the review of SCCmec in CNS, in this paper we report a 2-year surveillance of methicillin-resistant CNS in a tertiary-care hospital in Guadalajara, Mexico.

[Helicobacter pylori erradication and its relation to antibiotic resistance and CYP2C19 status]. / Erradicación de H. pylori y su relación con la resistencia a los antibióticos y el estatus de CYP2C19.

OBJECTIVE: to assess the efficacy of rabeprazole (RPZ), amoxicillin (Am), and clarithromycin (Cla) (7 vs. 14 days) in the eradication of H. pylori, and to determine the effect of strain-specific antibiotic resistance and host CYP2C19 status. MATERIAL AND METHODS: first, we determined the CYP2C19 status of 100 healthy subjects to establish a sample size for the clinical trial. Then, 59 H. pylori-infected patients were randomized to receive RPZ (20 mg daily) plus Cla (500 mg b.d.) and Am (1,000 mg b.d.) for 7 vs. 14 days. The MIC for Am and Cla were determined using the agar dilution method. The CYP2C19 genotype was determined by the PCR-RFLP method. RESULTS: In the per-protocol analysis (PP) eradication rates were 89.7 and 72% for the 7- and 14-day groups (p = 0.159). In the intention to-treat analysis (ITT) eradication rates were 86.7 and 62.1% in the 7- and 14-day groups, respectively (p = 0.06). None of the strains was resistant to Am, and 4 strains were resistant to Cla: 3 (11.1%) in the 14-day group and 1 (4%) in the 7-day group. Neither strain-specific antibiotic resistance nor host CYP2C19 status influenced eradication rates. CONCLUSIONS: both 7- and 14-day therapies were effective for H. pylori eradication. Strain resistance and CYP2C19 status do not seem to influence eradication rates in the studied population.

Erradicación de H. pylori y su relación con la resistencia a los antibióticos y el estatus de CYP2C19 / Helicobacter pylori erradication and its relation to antibiotic resistance and CYP2C19 status

Objetivo: determinar la eficacia del rabeprazol (RPZ), amoxicilina (Am) y claritromicina (Cla) (7 vs. 14 días) en la erradicación de H. pylori y determinar el efecto de la resistencia a los antibióticos y el genotipo de CYP2C19. Material y métodos: inicialmente, se determinó el genotipo de CYP2C19 a 100 sujetos sanos para determinar el tamaño de muestra del ensayo clínico. Posteriormente, 59 pacientes H. pylori+ recibieron al azar RPZ (20 mg diarios), Cla (500 mg cada 12 horas) y Am (1.000 mg cada 12 horas) (7 vs. 14 días). Se determinó la CMI para Am y Cla por el método de dilución en agar. El genotipo CYP2C19 fue determinado por PCR-RFLP. Resultados: en el análisis por protocolo (PP), las tasas de erradicación fueron del 89,7 y 72% para los grupos de 7 y 14 días respectivamente (p = 0,159). En el análisis de intención de tratamiento (IT), las tasas de erradicación fueron del 86,7 y 62,1% en los grupos de 7 y 14 días respectivamente (p = 0,06). Ninguna cepa presentó resistencia a Am y 4 cepas fueron resistentes a Cla: 3 (11,1%) en el grupo de 14 días y 1 (4%) en el grupo de 7 días. Las tasas de erradicación no fueron afectadas por la resistencia de la cepa o el genotipo de CYP2C19. Conclusiones: las terapias de 7 y 14 días fueron eficaces para la erradicación de H. pylori. Al parecer, la resistencia de la cepa y el genotipo de CYP2C19, no influenciaron las tasas de erradicación de H. pylori en la población estudiada

Objective: to assess the efficacy of rabeprazole (RPZ), amoxicillin (Am), and clarithromycin (Cla) (7 vs. 14 days) in the eradication of H. pylori, and to determine the effect of strain-specific antibiotic resistance and host CYP2C19 status. Material and methods: first, we determined the CYP2C19 status of 100 healthy subjects to establish a sample size for the clinical trial. Then, 59 H. pylori-infected patients were randomized to receive RPZ (20 mg daily) plus Cla (500 mg b.d.) and Am (1,000 mg b.d.) for 7 vs. 14 days. The MIC for Am and Cla were determined using the agar dilution method. The CYP2C19 genotype was determined by the PCR-RFLP method. Results: in the per-protocol analysis (PP) eradication rates were 89.7 and 72% for the 7- and 14-day groups (p = 0.159). In the intention to-treat analysis (ITT) eradication rates were 86.7 and 62.1% in the 7- and 14-day groups, respectively (p = 0.06). None of the strains was resistant to Am, and 4 strains were resistant to Cla: 3 (11.1%) in the 14-day group and 1 (4%) in the 7- day group. Neither strain-specific antibiotic resistance nor host CYP2C19 status influenced eradication rates. Conclusions: both 7- and 14-day therapies were effective for H. pylori eradication. Strain resistance and CYP2C19 status do not seem to influence eradication rates in the studied population

Characterisation of Helicobacter pylori isolates from the north-eastern region of Mexico.

The vacA and cagA genotypes of 50 Helicobacter pylori isolates from patients in the north-eastern region of Mexico were characterised by PCR, and the correlation between genotypes and different clinical outcomes was investigated. Strains of H. pylori that are vacA s1/m1 and cagA positive have previously been associated with more severe clinical outcomes, and some studies have shown differences in the vacA and cagA genotypes in different geographical regions. The six possible combinations of the vacA signal (s) and middle (m) regions were identified in this population, and the most frequent genotype was s2/m2. Thirty-two (64%) isolates were identified as cagA-positive. The s region was not amplified from seven of the cagA-positive isolates, and the m region was not amplified from one cagA-negative isolate, indicating that additional subfamilies of s and m genotypes may exist. The s1/m1 genotype was associated with cagA-positive strains (p < 0.05). No association was found between the vacA and cagA genotypes and clinical outcomes.

Antibiotic susceptibility patterns of Helicobacter pylori strains isolated from northeastern Mexico.

There are reports of increased antibiotic resistance rates in Helicobacter pylori strains around the world. The aim of this study was to determine the susceptibility patterns in H. pylori strains isolated in Monterrey, Mexico. We studied 62 strains isolated from the same number of symptomatic adult patients. Metronidazole (Mtz), clarithromycin (Cla), amoxicillin (Amx) and tetracycline (Tet) were tested by the E-test method. We observed that 37.1% of the strains were resistant to Mtz (MIC > or = 8 mg/L), and 8.1% to Cla (MIC > or = 8 mg/L), but we did not observe resistance to Amx (MIC > or = 2 mg/L) or Tet (MIC > or = 4 mg/L). In northeastern Mexico, the percentage of resistant strains was similar to that observed in developed countries. These results confirm that it is necessary to evaluate the susceptibility patterns of H. pylori strains by geographic area.

Mycolic acid index susceptibility method for Mycobacterium tuberculosis.

A rapid drug susceptibility test to measure the susceptibility of Mycobacterium tuberculosis to isoniazid (INH) and rifampin (RIF) using clinical isolates and a newly defined mycolic acid index (MAI) was evaluated. A total of 200 clinical isolates of M. tuberculosis were tested for susceptibility or resistance to INH and RIF by the MAI susceptibility and indirect-proportion methods. Overall, there was agreement between the two methods for 398 (99.5%) of the 400 total tests. Specifically, the sensitivity of the MAI susceptibility method for INH and RIF was 97.6 and 100%, respectively. The specificity and positive predictive value were 100% for both drugs, and the negative predictive value for INH and RIF was 98.3 and 100%, respectively. In conclusion, the MAI susceptibility method described here can be used for rapid drug susceptibility testing of M. tuberculosis clinical isolates within 5 days after clinical isolates are incubated in the presence or absence of an antituberculosis drug.