Patients exposed to vancomycin-resistant enterococci during in-hospital outbreaks in a low endemic setting: a proposal for risk-based screening.

BACKGROUND: The optimal extent of screening of contact patients (CoPat) after exposure to patients infected or colonized with vancomycin-resistant enterococci (VRE) remains controversial. METHODS: We retrospectively developed a new risk stratification for screening patients exposed to VRE, based on data from three outbreaks-two with Enterococcus faecium vanB and one with Enterococcus faecium vanA involving 1096 CoPat-in a low endemic setting. We classified them into four risk groups: three on environmental exposure, one by healthcare exposure: high (sharing the same room/bathroom with a VRE-colonized patient), medium (hospitalization in the same room after a VRE-colonized patient's discharge until terminal disinfection including ultraviolet C (UVc)-disinfection), low (hospitalized in the same room within three weeks before the VRE-colonized patient), and "staff" (screening of patients having the same medical care team). RESULTS: VRE-transmission occurred in 7.9% in the high-risk group compared to 0.6% and 0% in the medium and low risk groups. There was a significant trend to higher rates of transmission by risk level of exposure (p < 0.001). In the "staff" group, VRE transmission rate was 2.3%. CONCLUSION: Based on this stratification, we recommend to focus screening of exposed CoPat on the high-risk and "staff" group, saving resources and costs, but larger studies will allow to further improve the yield of VRE screening in the outbreak setting.

Occurrence of bacteriophages infecting Bacteroides host strains (ARABA 84 and GB-124) in fecal samples of human and animal origin.

Bacteriophage-based microbial source-tracking studies are an economical and simple way of identifying fecal sources in polluted water systems. Recently isolated Bacteroides spp. strains ARABA 84, and GB-124 have been shown to detect bacteriophages exclusively in aquatic systems impacted by human fecal material. To date, limited examination of the occurrence or concentration of phages capable of infecting Bacteroides fragilis strain GB-124 or B. thetaiotaomicron strain ARABA 84 in human and animal feces has been carried out. This study reports the prevalence rates and concentrations of phages infecting ARABA 84 and GB-124 host strains in human and a range of animal feces. Discrete human fecal samples (n=55) and pooled animal samples (n=46, representing the feces of over 230 animals) were examined for phages infecting the host strains ARABA 84, GB-124, and E. coli strain WG5. Both human Bacteroides host strains were highly specific (95% and 100% for ARABA 84 and GB-124, respectively), challenging results from previous studies. This study supports the use of Bacteroides strains GB-124 and ARABA 84 in fecal source tracking studies for the detection of human fecal contamination.

Assessment of source tracking methods for application in spring water.

For discriminating between human and animal faecal contamination in water, microbial source tracking (MST) approaches using different indicators have been employed. In the current study, a range of 10 such MST indicators described in the scientific literature were comparatively assessed. Bacteriophages infecting host strains of Bacteroides (GA-17, GB-124 and ARABA 84) as well as sorbitol-fermenting bifidobacteria proved useful for indicating human faecal contamination while Rhodococcus coprophilus was associated with animal-derived faecal contamination. These potential source indicators were present in samples of faecal origin, i.e. either in human wastewater or animal waste, from many different regions in Switzerland and therefore showed a geographic stability. In addition, the MST indicators were abundant in surface water and were even sensitive enough to detect faecal contamination in spring water from two study areas in Switzerland. This is the first study that has compared and successfully applied MST methods in spring water.

Performance of viruses and bacteriophages for fecal source determination in a multi-laboratory, comparative study.

An inter-laboratory study of the accuracy of microbial source tracking (MST) methods was conducted using challenge fecal and sewage samples that were spiked into artificial freshwater and provided as unknowns (blind test samples) to the laboratories. The results of the Source Identification Protocol Project (SIPP) are presented in a series of papers that cover 41 MST methods. This contribution details the results of the virus and bacteriophage methods targeting human fecal or sewage contamination. Human viruses used as source identifiers included adenoviruses (HAdV), enteroviruses (EV), norovirus Groups I and II (NoVI and NoVII), and polyomaviruses (HPyVs). Bacteriophages were also employed, including somatic coliphages and F-specific RNA bacteriophages (FRNAPH) as general indicators of fecal contamination. Bacteriophage methods targeting human fecal sources included genotyping of FRNAPH isolates and plaque formation on bacterial hosts Enterococcus faecium MB-55, Bacteroides HB-73 and Bacteroides GB-124. The use of small sample volumes (≤50 ml) resulted in relatively insensitive theoretical limits of detection (10-50 gene copies or plaques × 50 ml(-1)) which, coupled with low virus concentrations in samples, resulted in high false-negative rates, low sensitivity, and low negative predictive values. On the other hand, the specificity of the human virus methods was generally close to 100% and positive predictive values were ∼40-70% with the exception of NoVs, which were not detected. The bacteriophage methods were generally much less specific toward human sewage than virus methods, although FRNAPH II genotyping was relatively successful, with 18% sensitivity and 85% specificity. While the specificity of the human virus methods engenders great confidence in a positive result, better concentration methods and larger sample volumes must be utilized for greater accuracy of negative results, i.e. the prediction that a human contamination source is absent.

Improved detection of Rhodococcus coprophilus with a new quantitative PCR assay.

Agricultural practices, such as spreading liquid manure or the utilisation of land as animal pastures, can result in faecal contamination of water resources. Rhodococcus coprophilus is used in microbial source tracking to indicate animal faecal contamination in water. Methods previously described for detecting of R. coprophilus in water were neither sensitive nor specific. Therefore, the aim of this study was to design and validate a new quantitative polymerase chain reaction (qPCR) to improve the detection of R. coprophilus in water. The new PCR assay was based on the R. coprophilus 16S rRNA gene. The validation showed that the new approach was specific and sensitive for deoxyribunucleic acid from target host species. Compared with other PCR assays tested in this study, the detection limit of the new qPCR was between 1 and 3 log lower. The method, including a filtration step, was further validated and successfully used in a field investigation in Switzerland. Our work demonstrated that the new detection method is sensitive and robust to detect R. coprophilus in surface and spring water. Compared with PCR assays that are available in the literature or to the culture-dependent method, the new molecular approach improves the detection of R. coprophilus.

Identification of fecal input sites in spring water by selection and genotyping of multiresistant Escherichia coli.

The localization of fecal input sites is important for water quality management. For this purpose, we have developed a new approach based on a three-step procedure, including a preparatory phase, the screening of multiresistant bacteria using selective agar plates, and a typing phase where selected Escherichia coli isolates are characterized by antibiotic resistance profiles and molecular fingerprinting techniques (pulsed-field gel electrophoresis [PFGE]). These two well-known source tracking methods were combined in order to reduce cost and effort. This approach was successfully applied under field conditions in a study area located in the north-western part of Switzerland. E. coli isolates from spring water and surface water samples collected in this area were screened with selective agar plates. In this way, 21 different groups, each consisting of strains with the same pattern of antibiotic resistance, were found. Of these, four groups were further analyzed using PFGE. Strains with identical PFGE profiles were detected repeatedly, demonstrating the suitability of this method for the localization of fecal input sites over an extended period of time. Identical PFGE patterns of strains detected in water from two different springs were also found in the stream flowing through the study area. These results demonstrated the applicability of the new approach for the examination of incidents of fecal contamination in drinking water. The advantages of the described approach over genotyping methods currently being used to identify sources of fecal contaminants are a reduction in time, costs, and the effort required. Identical isolates could be identified without the construction of large libraries.

Novel Bacteroides host strains for detection of human- and animal-specific bacteriophages in water.

Bacteriophages active against specific Bacteroides host strains were shown to be suitable for detection of human faecal pollution. However, the practical application of this finding is limited because some specific host strains were restricted to certain geographic regions. In this study, novel Bacteroides host strains were isolated that discriminate human and animal faecal pollution in Switzerland. Two strains specific for bacteriophages present in human faecal contamination and three strains specific for bacteriophages indicating animal faecal contamination were evaluated. Bacteriophages infecting human strains were exclusively found in human wastewater, whereas animal strains detected bacteriophages only in animal waste. The newly isolated host strains could be used to determine the source of surface and spring water faecal contamination in field situations. Applying the newly isolated host Bacteroides thetaiotaomicron ARABA 84 for detection of bacteriophages allowed the detection of human faecal contamination in spring water.

Occurrence of Giardia lamblia in recreational streams in Basel-Landschaft, Switzerland.

Little is known about the environmental occurrence of the pathogenic organism Giardia lamblia in Switzerland. To provide a better insight into the importance of G. lamblia, a cheap, effective and easy to handle detection method was validated and evaluated in a series of field studies. G. lamblia was detected in 97.5% of surface water samples taken from two streams (Birs and Ergolz) located in the canton Basel-Landschaft, Switzerland. Since higher numbers of G. lamblia cysts were found after waste water treatment plants, human wastes appeared to be an important source of contamination. A correlation of G. lamblia with Escherichia coli and enterococci was observed. However, a linear equation to predict the number of G. lamblia cysts, given a concentration of E. coli or enterococci, did not prove to be suitable (r-squared = 0.27; r-squared = 0.24).