Carbapenemase producing Enterobacterales at a large teaching hospital in Ohio: comparison to state surveillance and retrospective analysis of patient characteristics.

Background: The presence of carbapenemase-producing carbapenem-resistant Enterobacterales (CP-CRE) around the world is increasing, particularly in healthcare settings. Surveillance testing for plasmid-mediated carbapenemase genes is necessary to tracking CP-CRE infections. Aim: In the state of Ohio, surveillance of carbapenem-resistant Enterobacterales (CRE) began in 2018, and to the authors' knowledge data on these cases has not been published to date. This study analyzed data on CRE from a large teaching hospital in Ohio, and by the Ohio Department of Health Laboratory (ODHL). Methods: Carbapenemase production was detected using mCIM, and plasmid-mediated carbapenemase genes were detected using rtPCR. Data was collected on 344 standard-of-care isolates from a large teaching hospital in Ohio, including data collected from chart review. Deidentified surveillance data on 4,391 CRE isolates was provided by the ODHL. Statistical analysis was performed using binary logistic regression. Findings: While KPC was the most common carbapenemase gene (n=1590), NDM (n=98), VIM (n=10), IMP (n=39) and OXA-48 (n=35) were also detected in the isolates studied. Klebsiella pneumoniae and Enterobacter cloacae were the most common CRE, and carbapenemase genes were most commonly detected in K. pneumoniae. Inpatient hospital stays and long-term care were associated with CP-CRE and were more common in women. Conclusion: Surveillance data shows that CP-CRE are present in Ohio, most commonly in Klebsiella pneumoniae. A better understanding of the prevalence of CRE, plasmid-mediated carbapenemase genes present, and the populations affected are important when tracking the spread of disease. Further study and surveillance of carbapenem-resistant organisms can provide a better understanding of their prevalence in the state.

An outreach activity to enhance biochemistry pedagogy.

Students are self-motivated to learn when provided opportunities that connect theory and real-world applications. Here, we describe for biochemistry majors a newborn screening-focused outreach activity that seeks to develop students' mastery of disciplinary content and soft skills (e.g., critical thinking, teamwork, effective communication, community engagement) and to enhance student engagement.

Equivalent Decline in Inflammation Markers with Tenofovir Disoproxil Fumarate vs. Tenofovir Alafenamide.

BACKGROUND: Initiation of antiretroviral therapy (ART) and subsequent virologic suppression reduces immune activation and systemic inflammation. METHODS: We examined longitudinal changes in biomarkers of monocyte activation (sCD14, sCD163), and systemic (IL-6, hsCRP, sTNFR-I and D-dimer) and vascular (Lp-PLA2) inflammation in a subgroup (N=100 per arm) of participants enrolled in a randomized, placebo-controlled trial comparing elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide (E/C/F/TAF; TAF) to E/C/F/tenofovir disoproxil fumarate (E/C/F/TDF; TDF) in treatment-naïve adults. RESULTS: For 194 participants (TAF, 98; TDF, 96), baseline levels of biomarkers did not differ by treatment arm; there were no differences in biomarker values between groups at weeks 12, 24, or 48 (p>0.05), except IL-6 at week 12 (p=0.012). Among all participants (combining groups), there were statistically significant declines from baseline observed for D-dimer, sCD163, and sTNFR-1 by week 12 and IL-6 by week 24. The proportion of participants with Lp-LA2 levels<200ng per mL (p=0.250) or hsCRP levels <3000mg per L (p=0.586) was unchanged through week 48. CONCLUSIONS: We observed equivalent declines in biomarkers of monocyte activation and systemic inflammation in treatment-naïve adults treated with TAF or TDF for 48weeks, suggesting that TAF and TDF have equivalent impact on immune activation and inflammation.

Jumping translocations, a novel finding in chronic lymphocytic leukaemia.

A jumping translocation (JT) is a rare cytogenetic aberration that can occur in haematological malignancy. It involves the translocation of the same fragment of donor chromosome onto two or more recipient chromosomes, typically in different cells. In this study, we describe the first series of chronic lymphocytic leukaemia (CLL) patients with JTs reported to date. Following a review of 878 CLL patient karyotypes, we identified 26 patients (3%) with 97 JTs. The most commonly occurring breakpoint in these translocations was 17p11.2. Loss of TP53 was identified prior to or at the same time as JT in 23 of 26 patients (88%). All patients eventually developed a complex karyotype. All but one patient has required treatment for CLL, with estimated median time to treatment of 11·5 months. This study establishes JTs as a recurrent abnormality found in CLL patients with aggressive disease. JTs contribute to complex karyotypes and, in many cases, are involved in chromosomal rearrangements that result in loss of the tumour suppressor gene TP53.

Evaluation of repetitive element polymerase chain reaction for surveillance of methicillin-resistant Staphylococcus aureus at a large academic medical center and community hospitals.

Repetitive element polymerase chain reaction (rep-PCR) typing has been used for methicillin-resistant Staphylococcus aureus (MRSA) strain characterization. The goal of this study was to determine if a rapid commercial rep-PCR system, DiversiLab™ (DL; bioMérieux, Durham, NC, USA), could be used for MRSA surveillance at a large medical center and community hospitals. A total of 1286 MRSA isolates genotyped by the DL system were distributed into 84 distinct rep-PCR patterns: 737/1286 (57%) were clustered into 6 major rep-PCR patterns. A subset of 220 isolates was further typed by pulsed-field gel electrophoresis (PFGE), spa typing, and SCCmec typing. The 220 isolates were distributed into 80 rep-PCR patterns, 94 PFGE pulsotypes, 27 spa, and 3 SCCmec types. The DL rep-PCR system is sufficient for surveillance, but the DL system alone cannot be used to compare data to other institutions until a standardized nomenclature is established and the DL MRSA reference library is expanded.

Purulent pericarditis secondary to community-acquired, methicillin-resistant Staphylococcus aureus in previously healthy children. A sign of the times?

RATIONALE: Purulent pericarditis secondary to community-acquired, methicillin-resistant Staphylococcus aureus (CA-MRSA) is a potentially lethal infection that has yet to be described in the pediatric population. Only four cases of purulent pericarditis secondary to CA-MRSA have been described in the English literature, all of whom were adults. OBJECTIVES: We report on the first two pediatric cases of purulent pericarditis secondary to CA-MRSA to increase awareness of this potentially fatal condition. METHODS: Clinical data were obtained from an 8-year-old male patient and a 7-month-old female patient, both previously healthy, who presented to our hospital for treatment of severe shock and multiorgan failure. Literature review was performed using MEDLINE and Cochrane databases. Pulsed-field gel electrophoresis was performed to confirm the organism type. MEASUREMENTS AND MAIN RESULTS: Our previously healthy patients presented with refractory shock and were found to have purulent pericarditis with tamponade secondary to CA-MRSA. Both patients required emergent pericardiocentesis and surgical pericardial debridement. Isolates from both patients were found to be MRSA USA type 300, a common type of CA-MRSA that has become the most frequent cause of skin and soft tissue infections in the United States. CONCLUSIONS: Purulent pericarditis survival hinges upon early empiric antibiotic therapy targeting resistant Staphylococcus, rapid diagnostic efforts, and expeditious pericardial drainage when diagnosed. An aggressive multidisciplinary approach provided for complete recovery in both cases, and both children were discharged with normal cardiac function. These two cases emphasize the need for consideration of CA-MRSA presenting with purulent pericarditis as an etiology for refractory shock.

Methicillin-resistant Staphylococcus aureus sequence type 239-III, Ohio, USA, 2007-2009.

Methicillin-resistant Staphylococcus aureus (MRSA) is a human pathogen that has diverse molecular heterogeneity. Most MRSA strains in the United States are pulsed-field gel electrophoresis USA100 sequence type (ST) 5 and USA300 ST8. Infections with MRSA ST239-III are common and found during health care-associated outbreaks. However, this strain has been rarely reported in the United States. As part of a study supported by the Prevention Epicenter Program of the Centers for Disease Control and Prevention (Atlanta, GA, USA), which evaluated transmission of MRSA among hospitals in Ohio, molecular typing identified 78 (6%) of 1,286 patients with MRSA ST239-III infections. Ninety-five percent (74/78) of these infections were health care associated, and 65% (51/78) of patients had histories of invasive device use. The crude case-fatality rate was 22% (17/78). Identification of these strains, which belong to a virulent clonal group, emphasizes the need for molecular surveillance.

Synergy testing by Etest, microdilution checkerboard, and time-kill methods for pan-drug-resistant Acinetobacter baumannii.

Pan-drug-resistant (PDR) Acinetobacter baumannii is an important nosocomial pathogen that poses therapeutic challenges. Tigecycline alone or in combination with agents such as colestimethate, imipenem, and/or amikacin is being used clinically to treat PDR A. baumannii infections. The purpose of this study was to compare in vitro susceptibility testing by epsilometric (Etest) methods and the checkerboard (CB) method with testing by time-kill analysis. PDR A. baumannii clinical strains representing eight unique pulsed-field gel electrophoresis clones selected from a total of 32 isolates were tested in vitro with tigecycline, colestimethate, imipenem, and amikacin in single- and two-drug combinations by using two different methods of Etest (with a fixed ratio method [method 1] and with the incorporation of the active drug in medium [method 2]) and by using CB. The three-drug combination of imipenem, tigecycline, and amikacin was also tested by CB. These results were compared to time-kill results. Synergy was consistently detected with the imipenem plus colestimethate and tigecycline plus imipenem combinations. The Etest method with active drug incorporated into the agar allowed us to detect synergy even in the presence of the active drug and was more comparable to CB and time-kill tests. Synergy was detected with the three-drug combination of imipenem, tigecycline, and amikacin by both CB and time-kill methods among several tested clones. These findings indicate the utility of synergy testing to predict activity of specific antibiotic combinations against PDR A. baumannii.

Pseudo-outbreak of Cupriavidus pauculus infection at an outpatient clinic related to rinsing culturette swabs in tap water.

Cupriavidus pauculus is a water microorganism rarely isolated from clinical specimens. We describe a pseudo-outbreak in which multiple strains that were associated with moistening of culturette swabs with tap water were isolated from a single clinic before collecting the patient specimen.

Antigenic and genetic characteristics of swine-origin 2009 A(H1N1) influenza viruses circulating in humans.

Since its identification in April 2009, an A(H1N1) virus containing a unique combination of gene segments from both North American and Eurasian swine lineages has continued to circulate in humans. The lack of similarity between the 2009 A(H1N1) virus and its nearest relatives indicates that its gene segments have been circulating undetected for an extended period. Its low genetic diversity suggests that the introduction into humans was a single event or multiple events of similar viruses. Molecular markers predictive of adaptation to humans are not currently present in 2009 A(H1N1) viruses, suggesting that previously unrecognized molecular determinants could be responsible for the transmission among humans. Antigenically the viruses are homogeneous and similar to North American swine A(H1N1) viruses but distinct from seasonal human A(H1N1).

Pulsed-field gel electrophoresis patterns and antimicrobial susceptibility phenotypes for coagulase-positive staphylococcal isolates from pustules and carriage sites in dogs with superficial bacterial folliculitis.

OBJECTIVE: To determine whether coagulase-positive staphylococcal isolates that are genotypically the same strain obtained from pustules and carriage sites of individual dogs with superficial bacterial folliculitis have the same antimicrobial susceptibility phenotype. ANIMALS: 40 dogs with superficial bacterial folliculitis. PROCEDURES: Samples were obtained from 3 pustules and 3 carriage sites (ie, anus, nonlesional axillary skin, and nasal mucosa) for bacterial culture, morphologic identification, Gram staining, catalase and coagulase testing, antimicrobial susceptibility testing, speciation, and pulsed-field gel electrophoresis (PFGE). RESULTS: 223 isolates from pustules and carriage sites were included. Seventeen susceptibility phenotypes were found among isolates. One hundred twenty-eight (100%) isolates from pustules and 95 (100%) isolates from carriage sites were susceptible to cephalothin; 128 (100%) isolates from pustules and 94 (98.9%) isolates from carriage sites were susceptible to amoxicillin-clavulanic acid; 114 (89.1%) isolates from pustules and 82 (86.3%) isolates from carriage sites were susceptible to erythromycin and lincomycin hydrochloride; and 103 (80.5%) isolates from pustules and 70 (73.7%) isolates from carriage sites were susceptible to trimethoprim-sulfamethoxazole. In 37 of 39 (94.9%) dogs, isolates with the same PFGE pattern from multiple pustules had the same susceptibility phenotype. In 21 of 33 (63.6%) dogs, isolates from multiple carriage sites with the same PFGE pattern had the same susceptibility phenotype. CONCLUSIONS AND CLINICAL RELEVANCE: In dogs with superficial bacterial folliculitis, most coagulase-positive staphylococcal isolates from pustules that are genotypically the same strain will have the same susceptibility phenotype and treatment may be based on empiric antimicrobial selection or susceptibility testing of 1 lesional isolate.

Genotypic relatedness of staphylococcal strains isolated from pustules and carriage sites in dogs with superficial bacterial folliculitis.

OBJECTIVE: To determine whether staphylococcal isolates cultured from pustules and carriage sites in dogs with superficial bacterial folliculitis were genotypically the same strain by use of pulsed-field gel electrophoresis (PFGE). ANIMALS: 40 dogs with superficial bacterial folliculitis. PROCEDURES: Samples were obtained from 3 pustules and 3 carriage sites (anus, axillary skin, and nasal mucosa). Bacterial culture, morphologic identification, Gram staining, catalase and coagulase tests, speciation, and PFGE were performed. RESULTS: Of 246 isolates, 203 were Staphylococcus intermedius, 5 were Staphylococcus aureus, 15 were Staphylococcusspp, and 22 were coagulase-negative staphylococcal isolates. No dog had an isolate with the same PFGE pattern as an isolate from another dog. Coagulase-positive isolates from multiple pustules and multiple carriage sites had the same PFGE pattern in 37 of 39 (94.9%) and 22 of 39 (56.4%) dogs, respectively. Coagulase-positive staphylococcal isolates from at least 1 pustule had the same PFGE pattern as an isolate from at least 1 carriage site in 34 of 36 (94.4%) dogs. Ninety-seven of 116 (83.6%) coagulase-positive staphylococcal isolates from pustules had the same PFGE pattern as an isolate from at least 1 carriage site. Sixty-nine of 91 (75.8%) coagulase-positive staphylococcal isolates from carriage sites had the same PFGE pattern as an isolate from at least 1 pustule. CONCLUSIONS AND CLINICAL RELEVANCE: Coagulasepositive staphylococcal strains were heterogeneous among dogs with superficial bacterial folliculitis. In individual dogs, strains from multiple pustules were genotypically the same, and strains from pustules were genotypically the same as strains from carriage sites.

Molecular epidemiology and cluster analysis of human listeriosis cases in three U.S. states.

To better understand the transmission and epidemiology of human listeriosis, 647 Listeria monocytogenes isolates obtained from human listeriosis cases in four U.S. locations (Michigan, Ohio, New York State, and New York City) over 61 months (1998 to 2003) were characterized by automated EcoRI ribotyping. A total of 65 ribotypes were differentiated among the characterized isolates; 393, 227, and 24 isolates were classified into lineages I, II, and III, respectively, and 3 isolates were not classified to lineage. The three most common ribotypes (responsible for 39% of all cases) represented L. monocytogenes epidemic clones, each of which had previously been linked to at least two human listeriosis outbreaks. Categorical analyses revealed that ribotypes and lineages were nonrandomly distributed among the four locations. Temporal cluster analysis of cases identified 13 statistically significant temporal subtype clusters, which represented 26% of all cases. Three of these clusters matched previously described human listeriosis outbreaks. Isolates involved in clusters belonged to nine ribotypes. Four, eight, and one cluster were caused by lineages I, II, and III, respectively. The two largest clusters were both caused by the epidemic clone representing ribotype DUP-1044A. Categorical analyses revealed no significant associations between lineage or ribotype and clinical manifestation (central nervous system infection, septicemia, fetal infection, or other infection) or disease outcome (fatal or not fatal). Although human listeriosis cases are caused by isolates belonging to a diversity of EcoRI ribotypes, specific lineage I epidemic clones cause a large number of human listeriosis cases. Many human listeriosis cases can be grouped into statistically significant temporal clusters, including widely distributed and region-specific clusters associated with isolates of various ribotypes. L. monocytogenes lineages and EcoRI ribotypes do not appear to differ in their likelihood of causing different clinical manifestations or mortality.

A multistate outbreak of Salmonella enterica serotype typhimurium infection linked to raw milk consumption--Ohio, 2003.

In December 2002, the Ohio Department of Health was notified of two children with Salmonella infection. Both had a history of drinking raw milk from a combination dairy-restaurant-petting zoo (dairy). The dairy was the only establishment in Ohio licensed to sell raw milk and reported 1.35 million visitors annually. We investigated to determine the extent of the outbreak and identify illness risk factors. A case patient was any person with pulsed-field gel electrophoresis-matched Salmonella enterica serotype Typhimurium from 30 November 2002 to 18 February 2003. Sixty-two met the confirmed case definition. Forty dairy case patient patrons were included in a case-control study; 56 controls were their well meal companions. Consumption of raw milk was found to be associated with illness (odds ratio, 45.1; 95% confidence interval, 8.8 to 311.9). The dairy discontinued selling raw milk. Because 27 other states still allow the sale of raw milk, awareness of the hazards of its consumption should be raised and relevant regulations carefully reviewed.

An outbreak of Escherichia coli O157 infection following exposure to a contaminated building.

CONTEXT: Infection with Escherichia coli O157 causes an estimated 70 000 diarrheal illnesses per year in the United States and can result in hemolytic-uremic syndrome and death. Environmental contamination with E coli O157 may be a public health problem. OBJECTIVES: To determine risk factors for E coli O157 infection during an outbreak investigation at a county fair and to evaluate environmental contamination as a possible cause of the outbreak. DESIGN, SETTING, AND PARTICIPANTS: Case-control study of 23 patients (median age, 15 years) and 53 age-matched controls who had attended the Lorain County, Ohio, fair between August 20 and August 26, 2001. Case-patients had laboratory-confirmed E coli O157 infection, hemolytic-uremic syndrome, or bloody diarrhea within 7 days of attending the fair; controls attended the fair and did not have diarrhea. MAIN OUTCOME MEASURES: Risk factors for infection and isolates of E coli O157 from environmental specimens. RESULTS: Six (26%) case-patients were hospitalized and 2 (9%) developed hemolytic-uremic syndrome. Case-patients were more likely than controls to have visited building A (a multipurpose community facility on the fairgrounds; matched odds ratio [MOR], 21.4 [95% confidence interval [CI], 2.7-170.7]). Among visitors to building A, illness was independently associated with attending a dance in the building (MOR, 7.5; 95% CI, 1.4-41.2), handling sawdust from the floor (MOR, 4.6; 95% CI, 1.1-20.0), or eating and/or drinking in the building (MOR, 4.5; 95% CI, 1.2-16.6). Twenty-four (44%) of 54 specimens collected from building A 6 weeks after the fair grew Shiga toxin-producing E coli O157. Isolates from sawdust, the rafters, and other surfaces were identical by molecular fingerprinting to patient isolates. Sawdust specimens collected 42 weeks after the fair also grew the same E coli O157 strain. CONCLUSIONS: Absence of evidence implicating specific food or beverage sources and the recovery of E coli O157 from the rafters suggest that airborne dispersion of bacteria contributed to the contamination. Because E coli O157 can survive in the environment for more than 10 months, humans may be at risk of infection long after an environment is initially contaminated.

Outbreaks of Escherichia coli O157 infections at multiple county agricultural fairs: a hazard of mixing cattle, concession stands and children.

Escherichia coli O157 infections cause an estimated 60 deaths and 73 000 illnesses annually in the United States. A marked summer peak in incidence is largely unexplained. We investigated an outbreak of E. coli O157 infections at an agricultural fair in Ohio and implicated consumption of beverages made with fairground water and sold by a geographically localized group of vendors who were all on the same branch of the fairground water distribution system. To examine county fair attendance as a risk factor for infection, we conducted two further epidemiological studies. In the first, we enhanced surveillance for E. coli O157 infections in 15 Northeast Ohio counties during the 2000 agricultural fair season and showed increased risk of E. coli O157 infection among fair attendees. In the second study, we examined Ohio Public Health Laboratory Information Service (PHLIS) data for 1999 using a time-varying covariate proportional hazards model and demonstrated an association between agricultural fairs and E. coli O157 infections, by county. Agricultural fair attendance is a risk factor for E. coli O157 infection in the United States and may contribute to the summer peak in incidence. Measures are needed to reduce transmission of enteric pathogens at agricultural fairs.