In vitro evaluation of different antimicrobial combinations against carbapenemase-producing Klebsiella pneumoniae: the activity of the double-carbapenem regimen is related to meropenem MIC value.

Objectives and methods: We evaluated the in vitro activity of different antimicrobial combinations with and without colistin against 39 carbapenem-resistant Klebsiella pneumoniae (CR-Kp) strains (colistin + meropenem/doripenem, colistin + tigecycline, colistin + rifampicin, gentamicin + meropenem, gentamicin + tigecycline and the double-carbapenem regimen meropenem + ertapenem) using the chequerboard method. The triple combination colistin + meropenem + tigecycline was also tested. In addition, killing studies were performed for meropenem + ertapenem. Results: Gentamicin-based combinations showed a high level of synergy. Meropenem + ertapenem was synergic in 12/39 (30.7%) of the strains, whereas based on killing studies 1 × MIC meropenem + 1 × MIC ertapenem and 2 × MIC meropenem + 1 × MIC ertapenem combinations were bactericidal and synergic at 24 h [mean area under the bactericidal curve (AUBC) 54.9 ±âŸ26.1 and 44.2 ±âŸ15.3 compared with 1 × MIC meropenem (134.5 ±âŸ40.1) and 2 × MIC meropenem (126.4 ±âŸ5.4), respectively, P < 0.0001]. When the results were stratified according to meropenem MIC, we found that the degree of synergy significantly increased for isolates with lower meropenem (and not ertapenem) MICs, up to an MIC of 128 mg/L. Among colistin-containing combinations, synergy was observed in 18/39 (46.1%), 33/34 (97%), 24/39 (61.5%) and 17/39 (43.5%) of the strains for colistin + meropenem, colistin + rifampicin, colistin + tigecycline and colistin + doripenem, respectively, including colistin-resistant strains. Colistin + meropenem + tigecycline at subinhibitory concentrations resulted in the absence of growth of 37/39 strains (94.8%). Conclusions: Our in vitro data suggest that colistin might be a valid therapeutic option against CR-Kp, even in the presence of colistin resistance, whereas the double-carbapenem regimen represents a viable option when colistin is not recommended, especially if the meropenem MIC is ≤ 128 mg/L. Since traditional antimicrobial susceptibility reports are not sufficiently informative for clinicians, synergy testing as well as actual meropenem MIC evaluation should always be performed in the case of CR-Kp infections.

Bactericidal and synergistic activity of double-carbapenem regimen for infections caused by carbapenemase-producing Klebsiella pneumoniae.

Available therapeutic options against carbapenem-resistant Klebsiella pneumoniae (CR-Kp) are limited because of the high level of resistance to other antimicrobial classes including polymyxins. The double-carbapenem regimen has been recently considered a possible therapeutic strategy. In the present study, we evaluated the in vitro bactericidal and synergistic activity of a double-carbapenem regimen consisting of ertapenem plus high-dose meropenem in a series of patients with healthcare-associated CR-Kp infections in whom the use of colistin was not indicated because of potential nephrotoxicity and/or resistance. In vitro synergy was evaluated using checkerboard and killing studies. A total of 15 patients were included in the study, with sepsis, severe sepsis and septic shock found in two (13.3%), five (33.3%) and one (6.7%) patients, respectively. Overall, the clinical/microbiological response was 12/15 (80%). Synergy was observed in 11/14 (78.6%) isolates using the checkerboard method whereas in killing studies 12/14 (85.7%) and 14/14 (100%) strains were synergistic and bactericidal at 24 h at concentrations of 1 × MIC MEM+1 × MIC ERT and 2 × MEM+1 × MIC ERT, respectively, with a significant decrease of log CFU/mL compared with other combinations (p <0.0001). The double-carbapenem regimen showed clinical and in vitro effectiveness in patients with CR-Kp infections.

Persistent elevation of serum CA 19-9 with no evidence of malignant disease.

BACKGROUND: Serum CA 19-9 is the mainstay marker for the diagnosis of biliopancreatic malignancies, though a persistent elevation can also be observed in various benign diseases. AIMS: In this study, a marked increase of serum CA 19-9 was seen in 10 patients who had no evidence of malignant disease. The possible causes of this finding are discussed. PATIENTS: Nine women and one man were studied, whose admitting diagnoses were as follows: pulmonary fibrosis in two, diabetes in two, non-ulcer dyspepsia in two, obesity in one, acute diarrhoea in one, colon diverticula in one and gastric ulcer in one. METHODS: Routine blood tests, tumour marker determinations, imaging studies and endoscopy were carried out at admission. RESULTS: Serum CA 19-9 levels ranged from 112 to 1338 IU/ml (mean 517 IU/ml). Abdominal ultrasonography, CT-scan, upper gastrointestinal X-ray series and gastrointestinal endoscopies were negative for malignancy. During the follow-up period (range 2-7 years) serum CA 19-9 values were persistently elevated in all patients. CONCLUSIONS: Our study shows that persistent and significant elevation of serum CA 19-9 can be found in non-malignant and non-cholestatic disease.

Non-O157 Shiga toxin-producing Escherichia coli isolated from diarrhoeic calves in Argentina.

Faecal samples from 76 diarrhoeic calves belonging to 36 farms located in the Pampas plain, Argentina, were examined for Shiga toxin-producing Escherichia coli (STEC). A total of 15 STEC strains were isolated from 12 (15.8%) calves which came from six different farms. All stx positive strains assayed by PCR were also positives in the Vero cell cytotoxicity test. The majority (60.0%) of the STEC strains carried the stx(1) gene. Twelve (80.0%) of the STEC isolates which belonged to serotypes O5:H- (n = 4), O26:H11 (n = 4), O26:H- (n = 1), O111:H- (n = 2), and O123:H38 (n = 1) were also enterohaemolysin (EHly) positive and carried the gene encoding for intimin (eae). All the stx positive strains were negative for the bfpA gene. Localized adherence to HEp-2 cells were observed in 83.3% of the eae+ STEC strains. STEC belonging to serotype O5:H- showed atypical biochemical properties, including urease production. Urease was also produced by two strains belonging to serotypes O153:H? and non-typeable, respectively. Resistance to three or more antibiotics was observed in 12 (80.0%) of the STEC isolates. Most of the serotypes of STEC recovered in this survey carried virulence traits that are associated with increased human and bovine pathogenicity. The present study shows that highly virulent STEC strains are being shed by diarrhoeic calves from farms located in a high incidence area of human STEC infections.

Humoral immune response to infectious agents in aborted bovine fetuses in Argentina.

The purpose of this study was to characterize the exposure of bovine aborted fetuses from beef and dairy herds of the humid pampas of Argentina to different infectious agents by the evaluation of fetal fluid antibodies. Presence of fetal antibodies to bovine viral diarrhea virus genotype 1 (BVDV-1), bovine herpes virus type 1 (BHV-1), Leptospira interrogans, Brucella abortus, and Neospora caninum was determined. Of the 95 fetuses processed, 66 came from 49 beef herds and 29 from 12 dairy herds. The average gestational age of the aborted fetuses was 7.1 months. Antibodies to the mentioned agents were detected in 65 of the 95 fetal fluids (68.4%). In addition, antibodies to more than one infectious agent were detected in 32 fetuses (33.7%), suggesting fetal exposure to multiple antigens during gestation. There were antibodies to BVDV-1, BHV-1, N. caninum and Leptospira interrogans in 43 (45.2%), 29 (30.5%), 26 (27.4%) and 5 (5.2%) specimens, respectively. Antibodies to B. abortus were not detected in any of the fetal fluids. The results of this study provide information on the determination of antibodies in fluids from bovine aborted fetuses exposed to different infectious agents in the region.

[Evaluation of 2 hemoculture media for the isolation of Brucella spp.]]. / Evaluación de dos medios de hemocultivo para el aislamiento de Brucella spp.

The diagnostic efficiency of two hemoculture media for the detection of different species of Brucella strains was evaluated. Strains of Brucella melitensis, Brucella suis, Brucella abortus, Brucella ovis, and Brucella abortus S19 were used. Each strain was diluted in phosphate buffer saline (PBS) to obtain a concentration of 10(5) colony forming units/ml (CFU/ml). Blood from goats, pigs, cattle, and sheep was mixed with the bacterial suspension to obtain a final concentration minor or equal to 10(3) CFU/ml. These blood samples were inoculated into the following media: (i) Hemobrucella (HB), (ii) Tryptose citrated broth 2% (CTB), and (iii) Controls without blood for B. melitensis and B.suis. Subculture in dishes and CFU/ml counts were made at the 1st, 3rd, 8th, 10th, 20th, and 30th post-inoculation (PI) day. Best results were obtained in the HB medium for all strains, except for B. suis, which due to the presence of a contaminant did not reach its maximum development in this medium. All strains were recovered from both media at 24 h PI, except B. ovis that was isolated from HB at 72 h PI and was not recovered from CTB. All strains remained viable for a shorter period in CTB. Under the proposed experimental conditions the HB medium was more sensitive than CTB. Future experiments should evaluate the utility of this commercial medium in clinical cases of animal brucellosis.

Aetiology of bovine abortion in Argentina.

Necropsies were performed on 354 fetuses from dairy and beef herds submitted from 1994 to 2000 to the diagnostic laboratories at Instituto Nacional de Tecnología Agropecuaria, Balcarce, Argentina. Samples from the fetuses were examined for pathogenic organisms and processed for microscopic examination. An aetiological diagnosis was made for 161 (45.5%) of the fetuses. No diagnosis was made for 193 (54.5%) fetuses. Infectious agents were isolated from 122 (34.4%) of the fetuses, bacterial agents being involved in 80 (22.6%) of these. The most common bacterial agents isolated from the fetuses were Brucella abortus in 28 fetuses, Campylobacter fetus in 26 cases, and Escherichia coli in 9 cases. Bovine herpesvirus and bovine viral diarrhoea virus were found in 9 and 6 cases, respectively. Neospora caninum was detected by an immunohistochemical technique in 26 cases (7.3%). Congenital abnormalities, dystocia and mummifications were found in 8, 19 and 11 cases, respectively.

Occurrence and characteristics of CS31A antigen-producing Escherichia coli in calves with diarrhoea and septicaemia in Argentina.

CS31A is a K88-related non-fimbrial adhesin first described on Escherichia coli strains isolated from diarrhoeic and septicaemic calves. In this report, CS31A antigen was screened by immunological methods and confirmed by PCR among bovine E. coli isolates. In addition, CS31A-producing strains were characterized with respect to different fimbrial antigens, O-serogroup and other properties related to virulence. Faecal or tissue specimens of 100 diarrhoeic or septicaemic calves and 27 older cattle with different pathologies from 71 outbreaks or individual cases that occurred in Buenos Aires province, Argentina, were examined. CS31A + E. coli strains were isolated from 21 (21.0%) calves from 16 outbreaks or individual cases. No CS31A + E. coli was detected in samples from cattle more than 1 year old. Fimbriae F5, F41, F17a and F17b were not detected among the CS31A-producing strains. Three (14.3%) of the CS31A+ E. coli strains expressed the F17c fimbria. All of the 21 isolates exhibited at least one property of septicaemic strains (resistance to serum, production of aerobactin or colicins) but none of them demonstrated heat-stable enterotoxigenic activity. CS31A + E. coli isolates belonged to 10 serogroups, more commonly O8, O7, O17 and O21. The results obtained here confirm the worldwide distribution of CS31A antigen in bovine E. coli strains. However, CS31A + or CS31A + /F17c + E. coli were less frequently isolated than they were in North hemisphere countries.

Effect of two commercial vaccines to Campylobacter fetus subspecies on heifers naturally challenged.

Efficacy of two commercial vaccines containing Campylobacter fetus subspecies on heifers naturally challenged by service with an infected bull was tested. Sixteen heifers were vaccinated parentally two times with 3 weeks as interval, eight with commercial vaccine A and the other eight with commercial vaccine B. Eight other heifers were used as unvaccinated controls. Forty days after the first vaccine dose, the heifers were served by an infected bull during 60 days. Measure of systemic immune response and identification of the microorganism from genital secretions by culture and immunofluorescent antibody test (IFAT) were done. Vaccinated and control heifers had a poor reproductive performance (pregnancy rates were 2/8, 3/8 and 0/8 in groups A, B and C, respectively) and were infected by both methods during breeding time and after it. Moreover, one heifer in the groups B and C remained infected until 300 days post-breeding time. Neither vaccinated nor control heifers had an important increment of systemic antibody level. Only, they had a slight increment of antibody level after the breeding period and it may be because of natural stimulus by the infected bull during the copula. Culture and IFAT yielded high correlation on identification of C. fetus subspecies.

Two-step (culture and PCR) diagnostic approach for differentiation of non-T. foetus trichomonads from genitalia of virgin beef bulls in Argentina.

Preputial fluids from 567 virgin Angus and Hereford bulls, 1-2 years old, were inoculated into Sutherland medium, and approximately 8.4% produced cultures with a protozoan suggestive of Tritrichomonas foetus. Under brightfield microscopy, large numbers of single-celled motile organisms with multiple anterior flagellae, a posterior flagellum, axostyle, and a visible undulating membrane were detectable. Motility was jerky and rolling, as described for T. foetus. Air-dried smears of cultures stained with Giemsa or Diff-Quick + iodine revealed an organism similar to T. foetus, although somewhat more rounded. Several organisms appeared to have four anterior flagellae. Scanning electron microscopy (5000x) of representative samples revealed four anterior flagellae on most organisms, and an axostyle that was consistently longer than that seen in T. foetus. Using pan-trichomonal primers and T. foetus-specific primers in a polymerase chain reaction (PCR) assay, amplification products of 372bp were detected in all virgin bull isolates, but only with the pan-trichomonal primers. Positive control isolates of T. foetus yielded amplification products of the expected size (372 and 347bp) with the two sets of primers, respectively. We conclude that these protozoa are not T. foetus, and note the similarity of these findings with those reported earlier in North American beef cattle. Because in several countries there is no legal treatment for bovine trichomonosis, veterinarians recommend slaughter of bulls with positive preputial cultures. The existence of easily mis-identified non-T. foetus trichomonads in the bovine prepuce suggests that the current "gold standard" diagnostic test (culture of preputial scrapings or washings) should be augmented with a more specific confirming test, such as the PCR employed in this study.

Humoral immune response to infectious agents in aborted bovine fetuses in Argentina

The purpose of this study was to characterize the exposure of bovine aborted fetuses from beef and dairy herds of the humid pampas of Argentina to different infectious agents by the evaluation of fetal fluid antibodies. Presence of fetal antibodies to bovine viral diarrhea virus genotype 1 (BVDV-1), bovine herpes virus type 1 (BHV-1), Leptospira interrogans, Brucella abortus, and Neospora caninum was determined. Of the 95 fetuses processed, 66 came from 49 beef herds and 29 from 12 dairy herds. The average gestational age of the aborted fetuses was 7.1 months. Antibodies to the mentioned agents were detected in 65 of the 95 fetal fluids (68.4

). In addition, antibodies to more than one infectious agent were detected in 32 fetuses (33.7

), suggesting fetal exposure to multiple antigens during gestation. There were antibodies to BVDV-1, BHV-1, N. caninum and Leptospira interrogans in 43 (45.2

) and 5 (5.2

) specimens, respectively. Antibodies to B. abortus were not detected in any of the fetal fluids. The results of this study provide information on the determination of antibodies in fluids from bovine aborted fetuses exposed to different infectious agents in the region.

Evaluación de dos medios de hemocultivo para el aislamiento de Brucella spp / [Evaluation of 2 hemoculture media for the isolation of Brucella spp.]]

The diagnostic efficiency of two hemoculture media for the detection of different species of Brucella strains was evaluated. Strains of Brucella melitensis, Brucella suis, Brucella abortus, Brucella ovis, and Brucella abortus S19 were used. Each strain was diluted in phosphate buffer saline (PBS) to obtain a concentration of 10(5) colony forming units/ml (CFU/ml). Blood from goats, pigs, cattle, and sheep was mixed with the bacterial suspension to obtain a final concentration minor or equal to 10(3) CFU/ml. These blood samples were inoculated into the following media: (i) Hemobrucella (HB), (ii) Tryptose citrated broth 2

(CTB), and (iii) Controls without blood for B. melitensis and B.suis. Subculture in dishes and CFU/ml counts were made at the 1st, 3rd, 8th, 10th, 20th, and 30th post-inoculation (PI) day. Best results were obtained in the HB medium for all strains, except for B. suis, which due to the presence of a contaminant did not reach its maximum development in this medium. All strains were recovered from both media at 24 h PI, except B. ovis that was isolated from HB at 72 h PI and was not recovered from CTB. All strains remained viable for a shorter period in CTB. Under the proposed experimental conditions the HB medium was more sensitive than CTB. Future experiments should evaluate the utility of this commercial medium in clinical cases of animal brucellosis.

Evaluación de dos medios de hemocultivo para el aislamiento de Brucella spp. / [Evaluation of 2 hemoculture media for the isolation of Brucella spp.]]

The diagnostic efficiency of two hemoculture media for the detection of different species of Brucella strains was evaluated. Strains of Brucella melitensis, Brucella suis, Brucella abortus, Brucella ovis, and Brucella abortus S19 were used. Each strain was diluted in phosphate buffer saline (PBS) to obtain a concentration of 10(5) colony forming units/ml (CFU/ml). Blood from goats, pigs, cattle, and sheep was mixed with the bacterial suspension to obtain a final concentration minor or equal to 10(3) CFU/ml. These blood samples were inoculated into the following media: (i) Hemobrucella (HB), (ii) Tryptose citrated broth 2

(CTB), and (iii) Controls without blood for B. melitensis and B.suis. Subculture in dishes and CFU/ml counts were made at the 1st, 3rd, 8th, 10th, 20th, and 30th post-inoculation (PI) day. Best results were obtained in the HB medium for all strains, except for B. suis, which due to the presence of a contaminant did not reach its maximum development in this medium. All strains were recovered from both media at 24 h PI, except B. ovis that was isolated from HB at 72 h PI and was not recovered from CTB. All strains remained viable for a shorter period in CTB. Under the proposed experimental conditions the HB medium was more sensitive than CTB. Future experiments should evaluate the utility of this commercial medium in clinical cases of animal brucellosis.

Humoral immune response to infectious agents in aborted bovine fetuses in Argentina.

The purpose of this study was to characterize the exposure of bovine aborted fetuses from beef and dairy herds of the humid pampas of Argentina to different infectious agents by the evaluation of fetal fluid antibodies. Presence of fetal antibodies to bovine viral diarrhea virus genotype 1 (BVDV-1), bovine herpes virus type 1 (BHV-1), Leptospira interrogans, Brucella abortus, and Neospora caninum was determined. Of the 95 fetuses processed, 66 came from 49 beef herds and 29 from 12 dairy herds. The average gestational age of the aborted fetuses was 7.1 months. Antibodies to the mentioned agents were detected in 65 of the 95 fetal fluids (68.4

). In addition, antibodies to more than one infectious agent were detected in 32 fetuses (33.7

), suggesting fetal exposure to multiple antigens during gestation. There were antibodies to BVDV-1, BHV-1, N. caninum and Leptospira interrogans in 43 (45.2

), 29 (30.5

), 26 (27.4

) and 5 (5.2

) specimens, respectively. Antibodies to B. abortus were not detected in any of the fetal fluids. The results of this study provide information on the determination of antibodies in fluids from bovine aborted fetuses exposed to different infectious agents in the region.

Demonstration of Listeria monocytogenes by immunohistochemistry in formalin-fixed brain tissues from natural cases of ovine and bovine encephalitis.

In the present work, evidence of Listeria monocytogenes antigens based on the avidin-biotin complex (ABC) immunoperoxidase technique was performed on formalin-fixed central nervous system tissues (CNS) from a total of 23 natural cases of encephalitis (four ovine and 19 bovine). Listeria monocytogenes serotype 4 was isolated from 10 of 17 cultured specimens. Meningoencephalitis characterized by focal necrosis, microabscesses, perivascular cuffing, and gliosis with presence of macrophages and/or neutrophils was observed at histological examination. Positive L. monocytogenes antigens were successfully identified by immunohistochemistry (IHC) in the CNS of all 23 cases. Paraffin-embedded tissues assayed were stored up for 17 years. Morbidity of the outbreaks was between 0.3-3% and 0.1-1% for ovine and bovine cases, respectively. In all the ovine cases, flocks involved were under extensive grazing conditions. In nine of the 19 bovine cases (47.3%), supplementation with corn silage was used. The ABC test can help as a practical tool for the diagnosis of natural cases of L. monocytogenes encephalitis on formalin-fixed specimens from ovine and bovine.

Campylobacter fetus diagnosis: direct immunofluorescence comparing chicken IgY and rabbit IgG conjugates.

In Argentina Bovine Genital Campylobacteriosis is routinely diagnosed by direct immunofluorescence test. Generally, the hyperimmune sera used for this test are obtained from rabbits and less often from goats. In this work, a chicken egg yolk immunoglobulin (IgY) extract was conjugated and its ability to detect campylobacters with the regular conjugate prepared with rabbit sera was comparatively evaluated. Both conjugates were independently evaluated by two laboratories, named "Azul" (Lab A) and "Balcarce" (Lab B). Animals were immunised with formalin inactivated Campylobacter (C.) fetus cells. Chicken IgY and rabbit IgG were conjugated with fluorescein isothiocyanate and used to comparatively examine strains of C. fetus subspp., other Campylobacter spp. and different bacterial species. Both conjugates had a high percentage rate of detection for C. fetus. IgY had less background due to unspecific fluorescence than IgG. IgY is a cheap, bloodless and very productive method. IgY can replace mammal immunoglobulins for C. fetus diagnosis.

Impaired fecal elastase excretion in uremic pancreopathy.

To evaluate pancreatic exocrine function in uremia, 25 patients undergoing regular hemodialysis without clinical evidence of pancreatic disease and 25 healthy control subjects were studied by fecal elastase 1 and chymotrypsin. Abdominal ultrasonography and measurement of serum lipase, calcium, phosphate, and parathormone were also carried out. Fecal elastase was significantly lower (P < 0.001) in patients than in controls. Abnormally low values were found in 12/25 patients of whom six had values <100 microg/g. Fecal chymotrypsin was significantly lower (P < 0.05) in patients than in controls, with lower than normal values found in 10/25 patients. Fecal elastase was not related to the serum calcium, phosphate, or parathormone levels or to the period of dialysis. In patients serum lipase was normal or slightly elevated (<300 units/liter), and there was no evidence of pancreatic disease at ultrasound examination. The results lend further support to the existence of pancreatic function impairment in a significant number of patients with renal failure despite the absence of clinical and morphological evidence of pancreatic disease.