Antibiofilm properties of triclosan with EDTA or cranberry as Foley Catheter lock solutions.

AIMS: To investigate the efficiency of triclosan, ethylenediaminetetraacetic acid (EDTA) and cranberry alone or in combinations against Escherichia coli strains as urinary catheter lock solutions to reduce catheter-associated urinary tract infections. METHODS AND RESULTS: Viable counting was used to assess antibiofilm activities for triclosan, EDTA and cranberry alone or in combinations against E. coli strains embedded in biofilm onto all-silicon Foley catheter surface. The results revealed that combination of triclosan (10 mg ml-1 /EDTA 30 mg ml-1 ) when filling the catheter balloon was able to eradicate and prevent biofilm formation among all tested E. coli including the resistant strains, whereas triclosan (8·5 mg ml-1 )/ cranberry (103 mg ml-1 ) combination was a successful catheter lock solution by preventing all tested strains from adhering onto catheter surface when filled via the eye hole. CONCLUSIONS: The combinations of triclosan/EDTA and triclosan/cranberry were significantly effective in eradicating and preventing biofilm formation of the tested E. coli strains on Foley catheters. SIGNIFICANCE AND IMPACT OF THE STUDY: Combinations of triclosan/EDTA and triclosan/cranberry have a promising application as nonantibiotic catheter lock solution.

Investigating possible association between multidrug resistance and isolate origin with some virulence factors of Escherichia coli strains isolated from infant faeces and fresh green vegetables.

AIMS: In this study, the association between multidrug resistance (MDR) and the expression of some virulence factors were evaluated in Escherichia coli strains isolated from infant faeces and fresh green vegetables. The effect of isolate origin on associated virulence factors was evaluated. In addition, genetic fingerprinting of a sample of these isolates (10 isolates from each group) was studied in order to detect any genetic relatedness among these isolates. METHODS AND RESULTS: Escherichia coli isolates were divided into four groups based on their origin (human faeces or plant) and their antibiotic resistance (multiresistance or susceptible). PCR was used to investigate heat-labile and heat-stable enterotoxin genes, and four siderophore genes (aerobactin, enterobactin, salmochelin and yersiniabactin). Genetic fingerprinting of the isolates was performed using enterobacterial repetitive intergenic consensus PCR. Siderophore production was measured by a colorimetric method. Biofilm formation was evaluated by a crystal violet assay. The results of the study showed that the expression of MDR is not significantly associated with an increase in these virulence factors or with biofilm formation. However, the origin of isolates had a significant association with siderophore gene availability and consequently on the concentrations of siderophores released. Genetic fingerprinting indicated that human and plant isolates have the same clonal origin, suggesting their circulation among humans and plants. CONCLUSION: Antibiotic-susceptible strains of E. coli may be as virulent as MDR strains. Results also suggest that the environment can play a potential role in selection of strains with specific virulence factors. SIGNIFICANCE AND IMPACT OF THE STUDY: Antibiotic-susceptible isolates of Escherichia coli from plant or human origin can be as virulent as the multidrug resistance (MDR) ones. Genetic relatedness was detected among the isolates of plant and human origin, indicating the circulation of these bacteria among human and plants. This could imply a potential role for environmental antimicrobial resistant bacteria in human infection.

Molecular epidemiology and evolution of A(H1N1) pdm09 and H3N2 viruses in Jordan, 2011-2013.

Understanding the genetic evolution of A(H1N1)pdm09 and H3N2 viruses can help better select strains to be included in the annual influenza vaccine. There is little information on their evolution in Jordan so this study investigated the genetic and antigenic variability of A(H1N1)pdm09 and H3N2 viruses in Jordan by performing phylogenetic and genetic analyses of the HA and NA genes of A(H1N1)pdm09 and H3N2 viruses between 2011 and 2013. The full HA and NA genes of 16 H1N1-positive samples obtained in our study and 21 published HA sequences and 20 published NA sequences from Jordanian viruses that were available on online gene databases were analysed. For H3N2, we generated 20 HA and 19 NA sequences and included 19 published HA and NA sequences each in the analysis. Jordanian H1N1 viruses had mutations that are characteristic of antigenic group 6 while H3N2 virus mutations belonged to group 3. No markers of resistance to oseltamivir were detected. The individual mutations are described in detail.

Molecular epidemiology and evolution of A[H1N1] pdm09 and H3N2 viruses in Jordan, 2011-2013

Understanding the genetic evolution of A [H1N1]pdm09 and H3N2 viruses can help better select strains to be included in the annual influenza vaccine. There is little information on their evolution in Jordan so this study investigated the genetic and antigenic variability of A[H1N1]pdm09 and H3N2 viruses in Jordan by performing phylogenetic and genetic analyses of the HA and NA genes of A[H1N1]pdm09 and H3N2 viruses between 2011 and 2013. The full HA and NA genes of 16 H1N1-positive samples obtained in our study and 21 published HA sequences and 20 published NA sequences from Jordanian viruses that were available on online gene databases were analysed. For H3N2, we generated 20 HA and 19 NA sequences and included 19 published HA and NA sequences each in the analysis. Jordanian H1N1 viruses had mutations that are characteristic of antigenic group 6 while H3N2 virus mutations belonged to group 3. No markers of resistance to oseltamivir were detected. The individual mutations are described in detail

La compréhension de l'évolution génétique des virus A[H1N1]pdm09 et H3N2 permet de mieux sélectionner les souches devant être ajoutées au vaccin antigrippal annuel. Peu de renseignements sont disponibles sur les mutations des virus saisonniers de la grippe A[H1N1]pdm09 et H3N2 en Jordanie. Afin de remédier à ce problème et d'étudier les variations génétiques et antigéniques des virus A[H1N1]pdm09 et H3N2, nous avons procédé à des analyses génétiques et phylogénétiques des gènes de l'hémagglutinine [HA] et de la neuraminidase [NA] de ces virus, sur la période 2011-2013 en Jordanie. L'analyse a porté sur les séquences complètes des gènes de l'HA et de la NA de 16 échantillons positifs au virus H1N1 prélevés dans le cadre de cette étude, ainsi que sur 21 séquences publiées de l'HA et 20 séquences publiées de la NA, issues de virus jordaniens disponibles sur les bases de données de gènes en ligne. Pour le virus H3N2, nous avons généré 20 séquences de l'HA et 19 de la NA, et avons également inclus dans l'analyse 19 séquences publiées de l'HA et 19 de la NA. Les virus H1N1 jordaniens présentaient des mutations caractéristiques du groupe antigénique 6, tandis que les virus H3N2 appartenaient au groupe 3. Aucun marqueur de résistance à l'oseltamivir n'a été détecté. Les mutations individuelles sont décrites en detail

Low intestinal colonization of Escherichia coli clone ST131 producing CTX-M-15 in Jordanian infants.

Over a period of 3 years' study (2012-2014), a total of 518 faecal samples were collected and cultured to isolate Escherichia coli. Of these, 338 (65.3%) E. coli isolates were recovered from infants, and 142/338 (42%) were multidrug-resistant (MDR) to ≥ 3 drug classes using the antimicrobial susceptibility disc diffusion method. A total of 125/142 (88%) of E. coli isolates were extended-spectrum ß-lactamase (ESBL) producers. blaCTX-M-15 types were observed in 80/125 (64%) of the isolates, and 60/80 (75%) were positive for blaCTX-M-15. Out of 338 E. coli isolates, 9 (2.6%) were positive for ST131/O25b clone and each isolate was associated with several plasmids of different sizes (1-21.2 kb). The identities of these nine isolates were confirmed by sequencing for presence of pabB (347 bp) and trpA (427 bp) genes. This study demonstrates low prevalence rate of the highly virulent E. coli ST131 clone producing blaCTX-M-15 in the intestines of Jordanian infants.

Middle East respiratory syndrome coronavirus not detected in children hospitalized with acute respiratory illness in Amman, Jordan, March 2010 to September 2012.

Hospitalized children < 2 years of age in Amman, Jordan, admitted for fever and/or respiratory symptoms, were tested for Middle East respiratory syndrome coronavirus (MERS-CoV): MERS-CoV by real-time RT-PCR (rRT-PCR). This was a prospective year-round viral surveillance study in children <2 years of age admitted with acute respiratory symptoms and/or fever from March 2010 to September 2012 and enrolled from a government-run hospital, Al-Bashir in Amman, Jordan. Clinical and demographic data, including antibiotic use, were collected. Combined nasal/throat swabs were collected, aliquoted, and frozen at -80°C. Specimen aliquots were shipped to Vanderbilt University and the Centers for Disease Control and Prevention (CDC), and tested by rRT-PCR for MERS-CoV. Of the 2433 subjects enrolled from 16 March 2010 to 10 September 2012, 2427 subjects had viral testing and clinical data. Of 1898 specimens prospectively tested for other viruses between 16 March 2010 and 18 March 2012, 474 samples did not have other common respiratory viruses detected. These samples were tested at CDC for MERS-CoV and all were negative by rRT-PCR for MERS-CoV. Of the remaining 531 samples, collected from 19 March 2012 to 10 September 2012 and tested at Vanderbilt, none were positive for MERS-CoV. Our negative findings from a large sample of young Jordanian children hospitalized with fever and/or respiratory symptoms suggest that MERS-CoV was not widely circulating in Amman, Jordan, during the 30-month period of prospective, active surveillance occurring before and after the first documented MERS-CoV outbreak in the Middle East region.

Multiple drug resistance and strength of attachment to surfaces in Pseudomonas aeruginosa isolates.

AIMS: To investigate the presence of a relationship between the strength of attachment of Pseudomonas aeruginosa to stainless steel surfaces and their observed multiple drug resistance. METHODS AND RESULTS: Multiple drug resistance of clinical and environmental isolates of Ps. aeruginosa was evaluated using disc diffusion method. The blot succession technique was used to quantify the strength of attachment of Ps. aeruginosa isolates. Different multiple drug-resistant Ps. aeruginosa isolates exhibited variable attachment strength. Although the highest multiple drug-resistant clinical isolate was shown to have the least attachment strength among clinical isolates, a weak correlation was found between attachment strength and multiple resistance among our investigated Ps. aeruginosa isolates. CONCLUSIONS: There is a weak correlation between multiple drug resistance and strength of attachment to stainless steel surfaces. SIGNIFICANCE AND IMPACT OF THE STUDY: Even low-resistant Ps. aeruginosa could have the potential of attaching firmly to surfaces and forming biofilm.

Characterization of antimicrobial resistance and class 1 integrons found in Escherichia coli isolates from human stools and drinking water sources in Jordan.

This study demonstrates that Escherichia coli isolates from human stools showed mostly higher minimum inhibitory concentrations (MICs) and significant rates of resistance (32%-67%, P<0.05) than Escherichia coli water isolates in Jordan, as follows: ampicillin (67% vs 28%), trimethoprim/sulfamethoxazole (67% vs 28%) nalidixic acid (63% vs 20%), cefuroxime (32% vs 4%), gentamicin (32% vs 17%), norfloxacin (32% vs 12%) and tetracycline (33% vs 16%). The prevalence of integron integrase genes (Intl1) in these isolates was also significantly higher in patients' stools (67%, P <0.05) than in water (36%), but the distribution of Sul 1/Sul 2 or both in association with postive Intl1 and resistance to ampicillin and sulfamethoxazole was not significantly higher (74% versus 62%, P <0.05) in isolates from stool and water. Plasmid profiles of representative multiresistant E. coli isolates from both sources indicated the presence of two common plasmids (49,25 kb) in 11/12 (91.6%), and all E. coli transconjugants were positive for class 1 integron markers (Intl 1, Sul 1 and Sul2) and mostly associated with three transferable drug-resistant determinants to ampicillin, sulfamethoxazole and tetracycline. These results indicate that class 1 integrons with conjugative R-plasmids are common and transferable among commensal antimicrobial multiresistant E. coli isolated from human feces and drinking water sources in Jordan.

Common antimicrobial resistance patterns, biotypes and serotypes found among Pseudomonas aeruginosa isolates from patient's stools and drinking water sources in Jordan.

Pseudomonas aeruginosa was isolated in low rates from stool specimens of outpatients and inpatients (7% versus 12%) but in higher rates from chlorinated and nonchlorinated water sources (15% versus 44%), respectively in Jordan. The same biotype was recognized among 90% of P. aeruginosa isolates from patient's stools and water sources using specific biochemical profiles. Three serogroups belonging to 01, 06 and 011 accounted for the majority of these isolates in water (66%) and stools (78%), respectively. All P. aeruginosa isolates from water were highly susceptible (87%-100%) to piperacillin-tazobactam, amikacin, gentamicin, imipenem, aztreonam, ceftazidime and ciprofloxacin, whereas the isolates from stool were slightly less susceptible (81%-98%) to these antimicrobials. P. aeruginosa isolates from water and stool sources were almost equally highly resistant to tetracycline (86%-89%) and carbenicillin (88%-89%), respectively. One common small plasmid (15.4 kb) was detected in 14/25 (56%) of multidrug-resistant P. aeruginosa isolates from both water and stool. This study demonstrates certain common epidemiological characteristics including antimicrobial resistance pattern, biotypes and serotypes among P. aeruginosa isolates from patient's stools and drinking water sources in Jordan.

Antimicrobial resistance and plasmid profiles of urinary Escherichia coli isolates from Jordanian patients.

We investigated antimicrobial resistance patterns and plasmid profiles of uropathogenic Escherichia coli isolates from inpatients and outpatients at Jordan University Hospital in 2000 and 2001. E. coli accounted for 32.4% and 37.4% of all isolates respectively. The lowest susceptibility was for ampicillin (11%), cotrimoxazole (23%) and tetracycline (26%). The relative incidence of resistant isolates of E. coli to nalidixic acid, gentamicin, norfloxacin, cefuroxime and nitrofurantoin was significantly greater for inpatients than for outpatients (P< 0.05). A large, transferable R-plasmid of 28 kb was found in most E. coli isolates (67%) that were resistant to at least ampicillin, cotrimoxazole and tetracycline. This R-plasmid reservoir may contribute to the spread of multiple antibiotic resistance in our Region.

Antimicrobial resistance and plasmid profiles of urinary Escherichia coli isolates from Jordanian patients

We investigated antimicrobial resistance patterns and plasmid profiles of uropathogenic Escherichia coli isolates from inpatients and outpatients at Jordan University Hospital in 2000 and 2001. E. coli accounted for 32.4% and 37.4% of all isolates respectively. The lowest susceptibility was for ampicillin [11%], cotrimoxazole [23%] and tetracycline [26%]. The relative incidence of resistant isolates of E. coli to nalidixic acid, gentamicin, norfloxacin, cefuroxime and nitrofurantoin was significantly greater for inpatients than for outpatients [P< 0.05]. A large, transferable R-plasmid of 28 kb was found in most E. coli isolates [67%] that were resistant to at least ampicillin, cotrimoxazole and tetracycline.This R-plasmid reservoir may contribute to the spread of multiple antibiotic resistance in our Region

Oral candidosis in patients with removable dentures.

The prevalence of Candida species with and without denture-related stomatitis were evaluated in 167 Jordanian patients. The study revealed that 47 (28%) of the patients with denture-related stomatitis were colonized with Candida species (clinical group). Candida albicans was responsible for most cases of denture-related stomatitis (72%), and it was the only species capable of secreting aspartic proteinases. The study also indicated that candidal colonization was not influenced by predisposing haematological deficiencies, as both the clinical and control patient groups showed comparable haematological parameters and the differences were not significant (P > 0.05). All Candida species isolates were 100% susceptible to amphotericin B, while these isolates were less susceptible (25-75%) to fluconazole.

Prevalence of Clostridium difficile-associated diarrhoea among hospitalized Jordanian patients.

We investigated stool specimens of 400 patients at Jordan University Hospital (300 patients with clinical diarrhoea and 100 controls without diarrhoea) for the presence of Clostridium difficile or its toxin. We found a 9.7% prevalence rate of C. difficile or its toxin in stools of patients with diarrhoea. The prevalence of other potential enteric pathogens, such as Salmonella spp. (2.3%), Shigella spp. (1.0%) and Entamoeba histolytica (2.7%), was significantly less. Prevalence of C. difficile or its toxin in controls was 3.0%. Toxin A was detected in 93.1% of C. difficile-associated diarrhoea cases using an enzyme immunoassay. Our study indicates that C. difficile-associated diarrhoea is mostly observed among hospitalized patients aged > or = 50 years, in association with antimicrobial treatment.

Prevalence of Clostridium difficile-associated diarrhoea among hospitalized Jordanian patients

We investigated stool specimens of 400 patients at Jordan University Hospital [300 patients with clinical diarrhoea and 100 controls without diarrhoea] for the presence of Clostridium difficile or its toxin. We found a 9.7% prevalence rate of C. difficile or its toxin in stools of patients with diarrhoea. The prevalence of other potential enteric pathogens, such as Salmonella spp. [2.3%], Shigella spp. [1.0%] and Entamoeba histolytica [2.7%], was significantly less. Prevalence of C. difficile or its toxin in controls was 3.0%. Toxin A was detected in 93.1% of C. difficile-associated diarrhoea cases using an enzyme immunoassay. Our study indicates that C. difficile-associated diarrhoea is mostly observed among hospitalized patients aged > or = 50 years, in association with antimicrobial treatment

High incidence of Klebsiella pneumoniae clinical isolates to extended-spectrum B-lactam drugs in intensive care units.

A prospective study conducted among Jordanian ICU patients in 1997 using Etest identified resistance rates among isolates of E. coli (25%-44%), Enterobacter spp. (54%-62%), and Klebsiella spp. (30%-80%) to extended-spectrum B-lactams (ESBLs): ceftazidime, cefotaxime, ceftriaxone, and aztreonam. All these isolates were susceptible to imipenem and showed low resistance rate to ciprofloxacin (5%-19%) and amikacin (13%-18%). Higher and significant resistance rates of Klebsiella isolates to ceftazidime (80%) and aztreonam (65%) were observed in 1997 compared with a previous study performed in 1994. The majority of Klebsiella pneumoniae (70%) express different ESBL phenotypes that were almost resistant to aztreonam and ceftazidime but susceptible or resistant to cefotaxime and/or ceftriaxone. This prospective study strongly suggests that ESBL production of Klebsiella pneumoniae isolates have been highly disseminated among ICU patients during 1997.

Frequency of nasal and wound isolates of Staphylococcus aureus associated with TSST-1 production in Jordanian population.

A total of 110 Staphylococcus aureus isolates were obtained from nasal carriers and wound infections of Jordanian population. The isolates were identified by cultural and biochemical methods. The nasal carrier rate of S. aureus among individuals was 22.7%. In comparison with the nasal S. aureus isolates the wound isolates did not produce significantly more virulence factors except DNase. Toxic shock syndrome toxin-1 production was higher among the S. aureus nasal isolates (40%) as compared with the wound isolates (26%) detected by an ELISA method which proved to be uniformly more sensitive than the immunodiffusion optimal sensitivity plate (OSP) method.

Multifactorial modelling for caries prediction in Jordanian university students.

OBJECTIVE: To construct a prediction model for caries experience in Jordanian university students using a number of explanatory risk factors as predictors. DESIGN: Data on salivary flow rate, buffering capacity, streptococci and lactobacilli counts, plaque accumulation, oral hygiene and between meal sugar intakes were tested as predictors of clinically and radiographically registered DMFS: Methods of analysis included correlation, then multiple regression, and finally dichotomisation of the DMFS data and application of discriminant analysis and logistic regression. The latter analyses were conducted in order to predict in which caries risk group an individual belonged rather than predicting (as with regression) their actual caries status. Two dichotomisation schemes were investigated; dichotomisation at the mean and at the 75th percentile. SETTING: The University of Jordan. PARTICIPANTS: A random sample of 180 university students (77 male and 103 female). OUTCOME MEASURES: Relationships were expressed as correlation coefficients, R2, and sensitivity, specificity and predictive values of the predictors, and also their validity and efficiency. RESULTS: The highest correlation coefficient achieved was 0.43 (P < 0.0001) between sugar-containing snack intakes and DMFS. The predicted power of the fitted multiple regression model was low R2 = 0.38). Logistic regression with the DMFS data dichotomised at the 75th percentile indicated that the fitted caries model correctly identified 76 per cent of the subjects. Sensitivity and specificity values of the predictive battery were 80 per cent and 75 per cent respectively. CONCLUSIONS: The multifactorial aetiology of caries remains unclear and requires further research. In the meantime, well-documented preventive measures should be implemented for this and similar populations.

Microbial infection and antibiotic resistance patterns among Jordanian intensive care patients

Microbial infections were observed in 30% [155/519] of all patients consecutively admitted in 1993 to the adult intensive care unit in the Jordan University Hospital in Amman. Gram-negative bacteria were involved in 110 [49%], Gram-positive bacteria in 69 [31%], mixed bacteria species in 25 [11%] and Candida spp. in 19 [9%] of all 223 infection episodes. Five species were isolated most frequently: Staphylococcus aureus [40], Acinetobacter spp. [28] Pseudomonas spp. [22], Enterobacter spp. [20] and Klebsiella spp. [17]. Resistance to most commonly available antibiotics was moderate to very high among Gram-positive and Gram-negative isolates. Almost all Gram-negative bacteria were sensitive to imipenem and ciprofloxacin

Extra-intestinal infections with multiply drug-resistant Salmonella typhimurium in hospitalized patients in Jordan.

During the 12-year period from 1978 to 1989, Salmonella typhimurium was the most frequently isolated serotype (592/1,500; 39.5%) among all clinical Salmonella isolates at Jordan University Hospital. Extra-intestinal infections due to Salmonella typhimurium accounted for 68 (11.5%) isolates. A high percentage of Salmonella typhimurium strains (52-90%) were resistant to commonly used drugs in Jordan. Most of the antibiotic-resistant strains of Salmonella typhimurium (10/12) examined which were from extra-intestinal sources contained a large plasmid (55 MDa) in addition to two to four small plasmids. These strains were also able to transfer most or part of their drug resistance in vitro. It is concluded that the invasive potential of Salmonella typhimurium isolates is probably associated with the presence of a large virulence plasmid and multiple antibiotic resistance.

Foodhandler-associated Salmonella outbreak in a university hospital despite routine surveillance cultures of kitchen employees.

OBJECTIVE: To describe an outbreak of salmonella food poisoning that probably was due to contamination of mashed potatoes by a foodhandler, which occurred despite a policy for routine surveillance stool cultures of kitchen employees. DESIGN: A case control study of 223 individuals who ate the lunch meal on September 23, 1989, at the Jordan University Hospital (JUH) cafeteria. SETTING: Tertiary care university hospital in Amman, the capital of Jordan. PATIENTS: Individuals who developed loose stool or vomiting 6 to 72 hours after eating the lunch meal of September 23, 1989, at the JUH cafeteria. RESULTS: Of 619 individuals, 183 fit the case definition (attack rate, 19.6%); 150 were employees, 26 were inpatients, and seven were visitors. Twelve other employees became sick 4 to 6 days later and probably were infected secondarily. The incubation period ranged from 16 to 72 hours in 183 instances. Symptoms included diarrhea (88%), fever (71%), abdominal pain (74%), dehydration (34%), and bloody stool (5%). Eighty-four were hospitalized. Cultures of eight food items were negative, but stool culture on 90 of 180 patients and 11 of 61 kitchen employees yielded Salmonella enteritidis group D. A cohort study of 223 individuals revealed a food-specific attack rate of 72% for the steak and potato meal and 18% for the rice and meat meal (RR, 4; CI95, 2.62 to 6.24; P < 0.01). Stratified analysis of the steak and potato meal revealed that the potatoes were implicated most strongly (RR, 1.93; CI95, 1.42 to 2.64; P < 0.01). Cultures were obtained from all kitchen employees, and 11 of 61 grew Salmonella enteritidis group D. One asymptomatic, culture-positive employee prepared the mashed potatoes on September 23. All of these employees had negative stool cultures 3 months earlier. CONCLUSION: This outbreak probably was caused by massive contamination of mashed potatoes by the contaminated hands of the foodhandler. Routine stool culture of foodhandlers is not cost-effective and should not be used as a substitute for health education and proper hygienic practices.