Molecular epidemiology of Burkholderia cepacia in two Australian cystic fibrosis centres.

Forty individual patient sputum isolates of Burkholderia cepacia from two Australian cystic fibrosis (CF) centres more than 100 km apart were genotyped using pulsed-field gel electrophoresis (PFGE) with XbaI restriction enzyme digestion. Hospital 1 had an endemic strain with 19 of 20 isolates being closely related. This centre does not implement an inpatient segregation policy for its paediatric patients who constitute the majority of those colonized with B. cepacia. Hospital 2 did not have a single endemic strain; there were two different sibling clusters and a third cluster involving a cohabiting couple, but all other patients had unique isolates. One patient at Hospital 2 carried an organism closely related to the endemic strain from Hospital 1. Hospital 2 practises segregation of colonized inpatients and also segregation external to the hospital. It would appear that no nosocomial spread of infection is occurring with this policy.

Evolution of an endemic methicillin-resistant Staphylococcus aureus population in an Australian hospital from 1967 to 1996.

The evolution over 30 years of a population of methicillin-resistant Staphylococcus aureus (MRSA) from a tertiary referral hospital was studied by phylogenetic analysis of SmaI-generated restriction fragment length polymorphisms (RFLPs). The results suggest that a new clone of MRSA appeared at the hospital in the early 1980s, which, although usually retaining its ancestral phage-type, developed four different RFLP pulsotypes in the next 16 years. This finding indicates that multiple RFLP patterns in MRSA do not necessarily represent multiple clones deriving from different mec gene transfer events. Such variation within a clone may be significant in the interpretation of RFLP patterns during outbreaks and emphasizes the need to use two typing methods in studies of such populations. Since the appearance of new clones of MRSA is a relatively rare event, cross-infection control is paramount in the prevention of MRSA dissemination.

Methicillin-resistant Staphylococcus aureus in a cystic fibrosis unit.

Methicillin-resistant Staphylococcus aureus (MRSA) infection in a cystic fibrosis (CF) unit was investigated. Two typing methods, phage-typing and restriction fragment length polymorphism (RFLP) by pulsed-field gel electrophoresis (PFGE) and phylogenetic analysis, showed that nonsocomial transmission of MRSA from the general hospital population had occurred. One instance of possible transmission between two patients was identified. However, transmission between two family members did not occur indicating a minimal risk of MRSA acquisition from social contact compared with hospital admission. This study supports policies for limiting CF-patient admission to hospital but transmission of MRSA does not appear to be a reason for limiting social contact with other CF patients.

Back to the future--the history and philosophy of medicine experiment at Sydney University.

History and Philosophy of Medicine has been a compulsory unit in the first year of the medical curriculum at Sydney University for the past decade. Volunteer tutors are drawn from most clinical and basic science departments, and each year the programme is organized on a theme of current importance in medical practice. This course began as an experiment because no resources were available for specialist staff, but has proved outstandingly successful in generating both student and teaching staff interest and support for the programme. Students present short tutorial papers to their peer group followed by submission of an essay which takes into account the tutorial discussion. The open book examination includes analysis of an unseen piece of primary source material as well as questions derived from the classwork. The Faculties of Arts and Science encouraged this educational experiment and several medical students have now opted to undertake a year of historical research during the intercalated B Sci(Med) programme, and a number of the tutors have enrolled in postgraduate historial or ethical programmes. We suggest that this model may permit introduction of novel courses in times of financial cutback within the Universities, and even allow a foundation to be laid for future development.

Typing multidrug-resistant Staphylococcus aureus: conflicting epidemiological data produced by genotypic and phenotypic methods clarified by phylogenetic analysis.

An outbreak of an unusual tetracycline-sensitive, rifampicin- and ciprofloxacin-resistant, methicillin-resistant Staphylococcus aureus (MRSA) strain at a large teaching hospital was investigated. Two typing methods, phage typing and restriction fragment length polymorphism (RFLP) by pulsed-field gel electrophoresis (RFLP-PFGE), gave conflicting results which were clarified by phylogenetic analysis. Phage typing identified all the "epidemic-associated" strains as identical, while RFLP-PFGE further divided these strains into four pulsotypes. Phylogenetic analysis showed these four pulsotypes were related genetically and also recognized a second strain of MRSA causing a continuing cross-infection problem. Variation in the RFLP-PFGE pattern was shown to occur following lysogenization of phage-sensitive MRSA. These results indicate that in analyzing outbreaks caused by subgroups of clonal organisms like MRSA, it is necessary to use at least two typing methods and that conflicts between these could be resolved by phylogenetic analysis.

Nasal carriage of Staphylococcus aureus in Australian (pre-clinical and clinical) medical students.

The nasal carriage of Staphylococcus aureus in 808 Australian medical students was studied. Five groups of students experienced varying degrees of clinical exposure in a hospital environment ranging from 0 to 42 months. The overall percentage of carriers among the five groups did not vary. However, with increasing clinical exposure there was a decrease in the percentage of isolates sensitive to all antibiotics tested, and an increase in the carriage of S. aureus resistant to three or more antibiotics. No carriers of methicillin-resistant S. aureus (MRSA) were detected. The comparative rates of S. aureus carriage between female and male students varied. The relevance of medical students as nasal carriers of S. aureus in the hospital environment today is discussed.

Serological typing of coagulase-negative staphylococci using monoclonal antibodies.

This investigation was to determine whether monoclonal antibodies (Mabs) could be used to differentiate coagulase-negative staphylococci (C-NS) at species and strain level. Mabs were produced to four Staphylococcus epidermidis strains, two S. haemolyticus strains, one S. saprophyticus strain and one S. warneri strain. A panel of nine antibodies was tested for species and strain specificity against five type strains and 65 clinical isolates of C-NS by enzyme-linked immunosorbent assay (ELISA). Species specificity was found with Mab D150 produced to one S. haemolyticus strain. Using Mab D150 and Mab D198 in conjunction, identification of 90% of S. haemolyticus isolates to species level was achieved. S. saprophyticus Mab K84 reacted with most other strains of C-NS tested but only three S. haemolyticus strains (16%). This finding provides further evidence that S. haemolyticus possesses different surface determinants to other C-NS which could form the basis of a typing scheme for S. haemolyticus using Mabs D150, D198 and K84.

Prevalence of peritonitis-associated coagulase-negative staphylococci on the skin of continuous ambulatory peritoneal dialysis patients.

The predominance of coagulase-negative staphylococci as normal skin flora is thought to be a factor in their association with episodes of peritonitis in patients undergoing continuous ambulatory peritoneal dialysis. We investigated the prevalence of peritonitis-associated strains on the skin of 28 patients undergoing peritoneal dialysis. Coagulase-negative staphylococci were the most frequently isolated organisms, comprising 47% of peritoneal dialysis fluid isolates and 59% of body site isolates. A total of 142 coagulase-negative staphylococci were speciated, tested for their antimicrobial sensitivity and slime production, and identified by phage typing and plasmid-profile analysis. Staphylococcus epidermidis was the most commonly identified species from both peritoneal dialysis fluid (73%) and body sites (53%). Multiple antibiotic resistance was common, and the greater proportion of isolates were resistant to methicillin; 63.6% of peritoneal dialysis fluid isolates and 61.7% of body-site isolates. S. haemolyticus isolates were significantly more resistant to methicillin than other species. By phage typing and plasmid-profile analysis it was shown that peritonitis was rarely caused by skin-colonizing strains. In only 3 of 14 patients were peritonitis-associated strains isolated as skin colonizers, and no patients developed peritonitis due to organisms previously isolated as skin colonizers.

A study of coagulase-negative staphylococci isolated from clinically significant infections at an Australian teaching hospital.

Some 151 isolates of coagulase-negative staphylococci isolated from patients at an Australian teaching hospital were characterized by biochemical analysis, antibiotic sensitivity patterns and slime production. S. epidermidis was the predominant species (64%) isolated from clinically significant infections, and all S. epidermidis isolates from true bacteremias produced slime. Forty-nine per cent were resistant to methicillin and 61% to gentamicin. S. haemolyticus isolates from clinically significant infections also showed antibiotic resistance and 80% were resistant to more than five antibiotics. The importance of coagulase-negative staphylococci as pathogens in this large teaching hospital was confirmed.

Observations on the resistance to drying of staphylococcal strains.

Death rates have been determined for staphylococcal strains dried on cotton blanket material and stored at room temperature in the dark and in the light. Methicillin-resistant Staphylococcus aureus (MRSA) strains that produced a golden pigment and had a wide distribution within the hospital survived for longer periods than MRSA strains that produced little pigment and had a restricted local distribution. Death rates of methicillin-sensitive strains of S. aureus at day 7 were similar to those of the general epidemic MRSA strains, and there was no significant difference between the death rates at day 7 of the local epidemic MRSA strains and the coagulase-negative strains.

Phage-typing patterns and lysogenicity of methicillin-resistant strains of Staphylococcus aureus from Sydney, Australia, 1965-85.

Methicillin-resistant strains of Staphylococcus aureus isolated at the Royal Prince Alfred Hospital since 1965 were differentiated by phage-typing and by their lysogenic status. Most of these strains were isolated during two periods, 1965-72 and 1976-85. Nearly all of the strains isolated in the first period had one of four phage-typing patterns. Strains with each typing pattern carried two prophages; these eight phages were all different, as characterised by serological grouping and lytic spectrum. Lysogenisation of the non-lysogenic strain 1489 with each of these phages narrowed its phage-typing pattern; the typing pattern of the double lysogens was generally similar to and occasionally identical with that of the host strain that had yielded the pair of phages. In the second period, strains with one of five other phage-typing patterns predominated. Representatives of each of these carried the lysogenic phage C. The first methicillin-resistant strain carrying this phage had been isolated in 1974. The current methicillin-resistant S. aureus strains thus appear to form a distinct group that can be differentiated from those seen in earlier years.

Lysogenicity of methicillin-resistant strains of Staphylococcus aureus.

The lysogenic status of 23 strains of methicillin-resistant Staphylococcus aureus, isolated at the Royal Prince Alfred Hospital, Sydney, since 1980, was studied. Twenty strains, belonging to the four predominant phage types isolated in this hospital, carried the same lysogenic phage which we have designated C. Three other phages were isolated from five strains belonging to phage type 84/85/90. The presence of phage C had little effect on the phage-typing pattern of the strains. Similarly, lysogenization with the other three phages did not result in a significant change in phage-typing patterns. However, when strain 1489, isolated in 1969, was lysogenized with these three phages, there was a change in phage-typing pattern. Lysogenization of this strain with phage 47T resulted in a marked loss of sensitivity to both group-I and group-III phages. The lysogenic status of these methicillin-resistant strains of S. aureus was compared with that of strains isolated between 1967 and 1970. There was no evidence that the strains isolated recently were either related to, or derived from, the earlier ones.

Strain differentiation in methicillin-resistant Staphylococcus aureus.

Three different systems were used to test 236 isolates of methicillin-resistant Staphylococcus aureus in an attempt to ascertain if more than one strain is responsible for the current problem of cross-infection by this organism in N.S.W. hospitals. The biochemical tests used were of little assistance. Phage typing, using the Basic International Set of typing phages at 100 x routine test dilution (RTD), provided evidence of the presence of several different strains. Phage type 83A/85/95/90/88 was the typing pattern of the predominant strain and the nest most frequent group was not typable. These results were often difficult to read. Five new phages were therefore isolated and found to be valuable as they produced easily identifiable patterns at RTD.