Complete genome sequence of Salmonella bacteriophage SS3e.

A Salmonella lytic bacteriophage, SS3e, was isolated, and its genome was sequenced completely. This phage is able to lyse not only various Salmonella serovars but also Escherichia coli, Shigella sonnei, Enterobacter cloacae, and Serratia marcescens, indicating a broad host specificity. Genomic sequence analysis of SS3e revealed a linear double-stranded DNA sequence of 40,793 bp harboring 58 open reading frames, which is highly similar to Salmonella phages SETP13 and MB78.

Anti-Shiga toxin immunoglobulin G antibodies in healthy South Korean slaughterhouse workers.

BACKGROUND: Slaughterhouse workers are in direct contact with cattle nearly every day. The purpose of this study was to survey the presence and distribution of anti-Shiga toxin 1 (Stx1) immunoglobulin G (IgG) in slaughterhouse workers, enabling a study of the serologic response to this toxin while working in an area at high-risk of Stx-producing Escherichia coli (STEC) infection. METHODS: One thousand seven hundred and twenty-nine serum samples from healthy slaughterhouse employees were collected and surveyed by indirect enzyme-linked immunosorbent assay (ELISA). RESULTS: Among the 5 slaughterhouse positions, slaughterers had the highest distribution of anti-Stx1 IgG values by an ELISA. Based on the ELISA values, 25% (433/1729) of the workers had anti-Stx1 IgG. Slaughterers, residual products handlers, inspectors, livestock hygiene controllers, and grading testers had anti-Stx1 IgG-positive rates of 28%, 25%, 20%, 19%, and 17%, respectively. The ELISA values of anti-Stx1 IgG increased with increases in the number of years worked by slaughterers, but not by residual products handlers, inspectors, livestock hygiene controllers, or grading testers. CONCLUSIONS: From these results, slaughterhouse workers are healthy and asymptomatic; slaughterers in particular are at high-risk for STEC exposure.

Occurrence and distribution of various genetic structures of class 1 and class 2 integrons in Salmonella enterica isolates from foodborne disease patients in Korea for 16 years.

We have investigated the distribution of integrons among 752 multidrug-resistant Salmonella isolates from human febrile and/or diarrheal patients during 1992-2007 and analyzed their genetic characteristics. Here, we report extensive integron analysis results within human isolates during the last 16 years. The gene or gene cassette(s) in the class 1 integrons found in the isolates were dfrA7, dfrA12-orfF-aadA2, aadA2, bla(PSE1), dfrA1-aadA1, dfrA17-aadA5, bla(OXA1)-aadA1, aadB-aadA1, aadA22, aadA1, and aac6'Ib-bla(OXA1)-aadA2. Class 2 integrons harboring dfrA1-sat2-aadA1 gene cassette were also found in four isolates. Twenty-nine isolates including one Salmonella Schleissheim isolate had two integrons harboring aadA2 and bla(PSE1) in their variable regions of 1.0 and 1.2 kb amplicons, respectively, which have been also found in Salmonella genomic island 1 (SGI1) of multidrug-resistant Salmonella Typhimurium DT104. The presence of SGI1 in Salmonella Schleissheim isolate was proved by SGI1-specific polymerase chain reaction. We first report a Salmonella Schleissheim having SGI1, Salmonella Typhimurium and Salmonella Heidelberg having the class 2 integron with dfrA1-sat2-aadA1 cassettes, Salmonella London with the aac6'Ib-bla(OXA1)-aadA2 gene cassette, Salmonella Chailey with the gene cassette of aadA22, and coexistence of two class 1 integrons carrying aadA22 and dfrA12-orfF-aadA2 in Salmonella Typhimurium.

In vitro synergism of ciprofloxacin and cefotaxime against nalidixic acid-resistant Salmonella enterica serotypes Paratyphi A and Paratyphi B.

Paratyphoid fever is considered an emerging systemic intracellular infection caused by Salmonella enterica serotypes Paratyphi A, B, and C. We performed in vitro time-kill studies on three clinical isolates of nalidixic acid-resistant Salmonella serotype Paratyphi (NARSP) with different concentrations of ciprofloxacin and cefotaxime to identify combinations of antibiotics with synergistic activity against paratyphoid fever. Furthermore, we identify the frequency of mutations to ciprofloxacin, cefotaxime, and rifampin resistance and also sequenced the gyrA, gyrB, parC, and parE genes to identify the cause of resistance in NARSP. When the activity of ciprofloxacin at 0.75x MIC (0.012 to 0.38 microg/ml) with cefotaxime at the MIC (0.125 to 0.25 microg/ml) against all three NARSP isolates was investigated, synergy was observed at 24 h, and the bacterial counts were reduced by >3 log(10) CFU/ml. This synergy was elongated for up to 72 h in two out of three isolates. When ciprofloxacin at 0.75x MIC (0.012 to 0.38 microg/ml) was combined with cefotaxime at 2x MIC (0.25 to 0.50 microg/ml), synergy was prolonged for up to 72 h in all three isolates. Both Salmonella serotype Paratyphi A isolates carried single mutations in codon 83 of the gyrA gene and codon 84 of the parC gene that were responsible for their reduced susceptibility to ciprofloxacin, while no mutations were found in the gyrB or parE gene. The ciprofloxacin-plus-cefotaxime regimen was very effective in reducing the bacterial counts at 24 h for all three isolates, and this combination therapy may be helpful in reducing the chance of the emergence of fluoroquinolone-resistant mutants in patients with severe paratyphoid fever.

Omics-based analysis of the luxS mutation in a clinical isolate of Escherichia coli O157:H7 in Korea.

The purpose of this study was to investigate the relationship between the global regulatory mechanism known as quorum sensing and expression of virulence factors in Escherichia coli O157:H7. A non-polar luxS deletion was introduced into the chromosome of strain CI03J, a human clinical isolate from South Korea, to create the DeltaluxS mutant strain ML03J. Phenotypic characterization of wild-type and mutant strains demonstrated that ML03J had no obvious growth or metabolic defects on 0.2% glucose LB medium, produced a functionally-defective flagellum, and could not utilize sorbose; the biological significance of sorbose utilization is unknown. Omics-based analysis revealed the involvement of LuxS in the transcriptional activation of several flagella/chemotaxis-related genes (flhD; fliA, C, D, S, Z; cheA, Y, and Z), repression of glutamate-dependent acid resistance genes (gadAB), and expression of virulence factors including Shiga toxin, hemolysin, and SepD within the LEE pathogenicity island.

Genetic characterization of atypical Shigella flexneri isolated in Korea.

Three types of serotypically atypical Shigella flexneri strains were isolated from 2007 to 2008 in patients at the Korea National Institute of Health (NIH). These strains were characterized and compared with serologically typical S.flexneri. One type of strain either displayed nonreacting typing or grouping sera, reacting strongly only with polyB antisera, which indicates this strain is S. flexneri (polyB:un). The second type displayed reactions with one of the typing sera (IV) and did not bind any grouping sera (IV:un). The remaining type of strain displayed a plural agglutination pattern, reacted with one typing sera (II), and bound with two grouping sera (II:(3)4,7(8)). Among these atypical strains IV:un and II:(3)4,7(8) strains showed higher multi-antibiotic resistance in ampicillin, streptomycin, and trimethoprim-sulfamethoxazole than typical strains. Furthermore, all II:(3)4,7(8) strains harbored integrons. This study suggests that these multiple antibiotic-resistant atypical S. flexneri are new subserotypes of S.flexneri that await further serological classification.

Prevalence, genetic diversity, and antibiotic susceptibility of Bacillus cereus strains isolated from rice and cereals collected in Korea.

Incidence and properties of Bacillus cereus strains naturally present in cereals were evaluated by phenotypic characterization, antibiotic susceptibility testing, and pulsed-field gel electrophoresis. Of 293 cereal samples tested, 73 (25%) contained B. cereus strains. Incidence of B. cereus isolates varied with respect to sample; they were found in 15 (37%) of 83 brown rice samples, 23 (37%) of 63 glutinous rice samples, 16 (21%) of 76 barley samples, and 19 (27%) of 71 Job's tears samples. All B. cereus isolates from cereals were positive for diarrheal toxin genes. The isolates were susceptible to most of the antibiotics tested, but they were highly resistant to ampicillin, cefepime, oxacillin, and penicillin. Of the genes assayed by the PCR technique, a high frequency of nheA (99%) and hblDC (84%) was found in the genomic DNA of cereal-associated isolates, whereas cytK was less common (55%). From the strains carrying the hblDC genes, 93% produced enterotoxin HBL. B. cereus isolates did not have significant genetic homology. The genetic diversity and toxic potential differ among the strains isolated from cereals. These results provide important information on toxin gene profiles of cereal-associated B. cereus for population studies.

Clustering analysis of Salmonella enterica serovar Typhi isolates in Korea by PFGE, ribotying, and phage typing.

Salmonella enterica serovar Typhi is a Gram-negative bacterium causing the acute febrile disease typhoid fever. In Korea from 2004 to 2006, a total of 51 Salmonella Typhi isolates were identified in stool and blood from healthy carriers and patients with or without overseas travel histories. In this study, antibiogram, pulsed-field gel electrophoresis (PFGE), and automated ribotyping were performed as molecular epidemiological methods with phage typing as a classical subtyping tool of the isolates. Only two isolates were multidrug resistant and 82.3% of the isolates were susceptible to 16 antimicrobial agents tested. When the dendrogram was created based on the PFGE results, the subtypes could be clustered into five groups by 80% similarity criterion. The PFGE patterns of 31 isolates (60.8%) belonged to Cluster 3, the predominant cluster in the study. Three overseas travel-associated cases were differentiated into Cluster 4 of which three isolates were nalidixic acid or multidrug resistant. Major phage type and ribotype were A and PvuII-436-8-S-6, respectively. This study also showed the prevalence of PFGE Cluster 3 in Korea by clustering analysis and the link between some typhoid cases and travel to Cambodia, India, or Indonesia.

An additional novel antimicrobial resistance gene cluster in Salmonella genomic island 1 of a Salmonella enterica serovar Typhimurium DT104 human isolate.

The multi-antimicrobial resistance gene cluster and its derivatives have been detected in Salmonella genomic island 1 (SGI1), which has been identified in the Salmonella enterica serovar Typhimurium, phage types DT104, DT12, DT120, and U302, as well as other Salmonella serovars, including Agona, Paratyphi B, Albany, Meleagridis, Newport, Cerro, Derby, Dusseldorf, Infantis, Kiambu, and Emek. We acquired 53 Salmonella Typhimurium DT104 isolates from diarrheal patients in Korea. From these isolates, we identified a novel antimicrobial resistance gene cluster as an additional gene cassette in SGI1 from a multi-antimicrobial resistant isolate. The minimum inhibitory concentration for this isolate against ampicillin and chloramphenicol was two to four times higher than those for other multi-antimicrobial-resistant Salmonella Typhimurium DT104 isolates. The new antimicrobial resistance gene cluster detected in this isolate consisted of bla(PSE-1), sul1 Delta, floR, and tetR, in that order. The order of this gene cluster was shuffled as compared to that of the known In104 in SGI1. This report is, to the best of our knowledge, the first to identify and describe an additional shuffled antimicrobial resistance gene cluster in SGI1.

Genotypic and phenotypic diversity of Salmonella enteritidis isolated from chickens and humans in Korea.

Salmonella Enteritidis is the most common cause of salmonellosis in humans in South Korea. It has been recognized that the principal source of human infection with S. Enteritidis is chickens and their products such as meat and eggs. A total of 173 S. Enteritidis isolates from humans (65 isolates) and chickens or their products (108 isolates) were analyzed by antibiotic susceptibility assay, phage typing, and pulsed-field gel electrophoresis (PFGE). Drug resistance was found to streptomycin (32.3%), ampicillin (30.6%), nalidixic acid (30.1%), ticarcillin (30.1%), and tetracycline (28.3%). More than 70% of the isolates were found to be resistant to one or more antibiotics tested. The most frequent patterns of resistant isolates were resistance to nalidixic acid only (28.3%) and resistance to two antibiotics (four combinations; 20.2%). The most predominant phage type (PT) was PT1 (27.2%) followed by PT21 (20.8%) and PT4 (8.7%) in chicken and human isolates. Nineteen different PFGE patterns were found among the 173 isolates, and A1 was the most common PFGE pattern, followed by A6 (17.3%). Most S. Enteritis isolates (except two isolates with patterns B and C) showed similar PFGE patterns that differed by only a few bands. These results show that 2 or 3 subtypes of S. Enteritidis are shared to a large extent by humans and chickens. This implies the possibility of the spread of chicken S. Enteritidis to humans.

Detection of cytolethal distending toxin and other virulence characteristics of enteropathogenic Escherichia coli isolates from diarrheal patients in Republic of Korea.

Cytolethal distending toxins (CDTs) represent an emerging family of newly described bacterial products that are produced by a number of pathogens. The genes encoding these toxins have been identified as a cluster of three adjacent genes, cdtA, cdtB, and cdtC, plus 5 cdt genetic variants, designated as cdt-I, cdt-II, cdt-III, cdt-IV, and cdt- V, have been identified to date. In this study, a general multiplex PCR system designed to detect Escherichia coli cdts was applied to investigate the presence of cdt genes among isolates. As a result, among 366 E. coli strains, 2.7% were found to carry the cdtB gene. In addition, the use of type-specific primers revealed the presence of cdt-I, cdtIV, and cdt-V types of the cdt gene, yet no cdt-II or cdt- III strains. The presence of other virulence genes (stx1, stx2, eae, bfp, espA, espB, and espD) was also investigated using a PCR assay. Among the 10 cdtB gene-positive strains, 8 were identified as CDT-producing typical enteropathogenic E. coli (EPEC) strains (eae(+), bfp(+)), whereas 2 were identified as CDT-producing atypical EPEC strains (eae(+), bfp(-)). When comparing the cytotoxic activity of the CDT-producing typical and atypical EPEC strains, the CDT-producing atypical EPEC strains appeared to be less toxic than the CDT-producing typical EPEC strains.

Phage types and pulsed-field gel electrophoresis patterns of Salmonella enterica serovar Enteritidis isolated from humans and chickens.

We analyzed 66 Salmonella Enteritidis isolates in 2002. Thirty isolates were obtained from human patients with diarrhea, and 36 were obtained from chickens. A total of ten phage types (PT) were identified in the human and chicken isolates. PT1 and PT21 were the predominant PTs in both the human (20% and 13%) and chicken (17% and 47%) isolates. Twelve pulsotypes were generated by PFGE and divided into two major groups. Most of the PFGE types were categorized into cluster group 1. Eighteen chicken isolates in cluster group 1 showed high-level genetic association (>95%) with 22 other human isolates. Additionally, six chicken isolates from cluster group 2 showed fairly high-level genetic association (>95%) with the other seven human isolates. The highest levels of genetic association in humans and chickens were seen with A5-PT21 (11 isolates), A2-PT1 (7 isolates), and B1-PT4 (6 isolates). The Pulsed-Field Gel Electrophoresis (PFGE) and phage typing provided conclusive evidence that human Salmonella infections are attributable to the consumption of contaminated chicken.

Enteric bacteria isolated from acute diarrheal patients in the Republic of Korea between the year 2004 and 2006.

In an epidemiological survey of human enterobacterial infections in the Republic of Korea during three years from 2004 to 2006, we isolated 1,784 (6.2%, isolation rate of enteropathogens from stool samples) in 2004, 2,547 (9.5%) in 2005 and 3,506 bacteria (12.3%) from people who visited clinics. Among the isolated bacteria, pathogenic Escherichia coli, especially, EAEC was the most frequently identified pathogen in both urban and rural regions followed by Staphylococcus aureus, Salmonella species, Bacillus cereus, Vibrio parahaemolyticus, Campylobacter jejuni, Clostridium perfringens, and Shigella species. Distinct seasonality was found in V. parahaemolyticus species, while this pathogen showed no age-specific patterns. However, other bacteria, i.e., pathogenic E. coli, S. aureus, Salmonella spp., and B. cereus showed similar seasonality throughout the year, showing a slight increase in the infection rate during the summer months and high prevalence among children under 10 years of age and elder-age people. The antibiotic susceptibility patterns of pathogenic E. coli, Salmonella spp., and S. aureus showed high resistance to penicillins. However, both pathogenic E. coli and Salmonella spp. were susceptible to several cephems, imipenem, and amikacin. Moreover, S. aureus strains resistant to vancomycin were not found. In conclusion, these surveillances can play an important role for the control and prevention to the diseases originated by enteritis bacteria.

Surveillance of stool samples for the presence of Enterobacter sakazakii among Korean people.

PURPOSE: Enterobacter sakazakii (E. sakazakii) infections are an important cause of life-threatening meningitis, septicemia, and necrotizing enterocolitis in infants. Dried infant formula milk is an important vehicle for E. sakazakii infection. E. sakazakii was isolated in Korea from dried infant formula milk. Although E. sakazakii infection of infants may occur in Korea, its prevalence has not yet been documented. Therefore, we determined the prevalence of E. sakazakii and documented symptoms. MATERIALS AND METHODS: Between March and October 2006, 1,146 stool samples were collected from patients at Uijeongbu St. Mary's Hospital. Each fecal swab was dissolved in 10mL of buffered peptone solution, and enriched culture was streaked onto Druggan-Forsythe-Iversen (DFI) agar. Presumptive E. sakazakii colonies that exhibited a blue-green color during culture on DFI medium were selected. The identity of colonies that developed yellow pigment during culture on TSA was determined using the Vitek system and PCR. RESULTS: We isolated 4 E. sakazakii strains whose 16S rRNA sequence alignments had a similarity of 99% with those of 3 E. sakazakii ATCC strains. CONCLUSION: This is the first report on isolation of E. sakazakii from stool samples and to document the symptoms of Korean patients.

Molecular characterization of regulatory genes associated with biofilm variation in a Staphylococcus aureus strain.

Biofilm formation in association with the intercellular adhesion (icaADBC) gene cluster is a serious problem in nosocomial infections of Staphylococcus aureus. In all 112 S. aureus strains tested, the ica genes were present, and none of these strains formed biofilms. The biofilm formation is known to be changeable by environmental factors. We have found about 30% of phase variation in these strains with treatment of tetracycline, pristinamycin, and natrium chloride. However, this phenotype disappeared without these substances. Therefore, we have constructed stable biofilm-producing variants through a passage culture method. To explain the mechanism of this variation, nucleotide changes of ica genes were tested in strain S. aureus 483 and the biofilm-producing variants. No differences of DNA sequence in ica genes were found between the strains. Additionally, molecular analysis of three regulatory genes, the accessory gene regulator (agr) and the staphylococcal accessory regulator (sarA), and in addition, alternative transcription factor sigma B (sigB), was performed. The data of Northern blot and complementation showed that SigB plays an important role for this biofilm variation in S. aureus 483 and the biofilm-producing variants. Sequence analysis of the sigB operon indicated three point mutations in the rsbU gene, especially in the stop codon, and two point mutations in the rsbW gene. This study shows that this variation of biofilm formation in S. aureus is deduced by the role of sigB, not agr and sarA.

Multilocus sequence typing analysis of Shigella flexneri isolates collected in Asian countries.

The multilocus sequence typing scheme used previously for phylogenetic analysis of Escherichia coli was applied to 107 clinical isolates of Shigella flexneri. DNA sequencing of 3423 bp throughout seven housekeeping genes identified eight new allele types and ten new sequence types among the isolates. S. flexneri serotypes 1-5, X and Y were clustered together in a group containing many allelic variants while serotype 6 formed a distinct group, as previously established.

Molecular differentiation of common promoters in Salmonella class 1 integrons.

The integron is a mobile gene element which harbors antibiotic-resistance gene cassettes capable of site-specific integration. Among the four known types of integrons, the class 1 integron has been associated with multidrug-resistance in pathogenic bacteria. These gene cassettes have been the focus of a series of studies. The gene cassettes share a common promoter, and their expression levels are affected not only by their proximity to the promoter, but also by the strength (weak, hybrid and strong) of the common promoter, P1, as well as the presence of the additional promoter, P2. In this study, we developed molecular methods for the differentiation of promoter structures using PCR, restriction enzyme analysis, and polyacrylamide gel electrophoresis, and have applied them to the characterization of class 1 integrons in 33 non-typhoidal Salmonella serotypes in Korea. Class 1 integrons were detected in four serotypes: S. Derby (SD), S. Istanbul (SI), S. Paratyphi B (SPB), and S. Livingstone (SL), and the amplicon sizes were 1.0 Kb (SD, SI and SPB) and 2.0 Kb (SL). All of the 1.0 kb amplicons harbored gene cassettes (aadA1 or aadA2), but the 2.0 kb amplicon harbored three (dhfrXII-orfF-aadA2) gene cassettes, which conferred streptomycin/spectinomycin (aadA) and trimethoprim (dhfr) resistances. Our promoter structure study revealed three types of promoters; strong P1 (SD), weak P1 (SPB and SL), and weak P1+P2 (SI). In conclusion, the class 1 integrons were detected in Korean NTS, and their promoter structures were found to be variable. Therefore, our methods may prove helpful in terms of our understanding of molecular diversity, as well as the transmission of class 1 integrons and phenotype-genotype relationships in antibiotic-resistance.

A pulsed-field gel electrophoresis typing scheme for Vibrio parahaemolyticus isolates from fifteen countries.

Vibrio parahaemolyticus is an important foodborne pathogen in Taiwan and many other maritime Asian countries where seafood is frequently consumed. A total of 535 strains of V. parahaemolyticus were recovered mostly (97%) from clinical samples obtained in Taiwan or in 14 other countries. These strains were typed by pulsed-field gel electrophoresis following SfiI digestion and a typing scheme was generated. The 115 different patterns identified were grouped into 13 types with dissimilarity values less than 15, plus 16 miscellaneous patterns not grouped into any of the types. Types I, A, D and J contained the most patterns, with the numbers of patterns being 17, 13, 12, and 11, respectively. However, types I, B, D, A, H and C contained the most strains, with the numbers of strains being 204, 73, 71, 54, 29 and 25, respectively. Type I consisted exclusively of the pandemic O3:K6 strains and genetically closely related strains. This PFGE typing scheme for V. parahaemolyticus could be used for the characterization of pathogenic isolates.

Isolation of Salmonella enterica subspecies enterica serovar Paratyphi B dT+, or Salmonella Java, from Indonesia and alteration of the d-tartrate fermentation phenotype by disrupting the ORF STM 3356.

Salmonella enterica subspecies enterica serovar Paratyphi B [O1,4,(5),12 : Hb : 1,2] can cause either an enteric fever (paratyphoid fever) or self-limiting gastroenteritis in humans. The d-tartrate non-fermenting variant S. enterica subsp. enterica serovar Paratyphi B dT- (S. Paratyphi B) is the causative agent of paratyphoid fever, and the d-tartrate fermenting variant S. enterica subsp. enterica serovar Paratyphi B dT+ (S. Paratyphi B dT+; formerly called Salmonella Java) causes gastroenteritis. S. Java is currently recognized as an emerging problem worldwide. Twelve dT+ S. Java isolates were collected in Indonesia between 2000 and 2002. One-third of them contained Salmonella genomic island 1 (SGI1), which gives the multidrug-resistant phenotype to the bacteria. In this study, a PCR-based method to detect a single nucleotide difference responsible for the inability to ferment d-tartrate, reported elsewhere, was validated. The d-tartrate fermenting phenotype of S. Java was converted to the non-fermenting phenotype by the disruption of the ORF STM 3356, and the d-tartrate non-fermenting phenotype of the ORF STM 3356-disrupted strain and the dT- reference strain was changed to the dT+ phenotype by complementing ORF STM 3356 in trans. The results show that the dT+ phenotype requires a functional product encoded by STM 3356, and support the use of the PCR-based discrimination method for S. Paratyphi B and S. Java as the standard differentiation method.

Surveillance of bacterial pathogens associated with acute diarrheal disease in the Republic of Korea during one year, 2003.

An epidemiological survey of human enterobacterial infections was conducted to determine the prevalence of enteropathogens in the Republic of Korea during one year, 2003. We tested for infectious diseases in 26,992 stool samples obtained from people who visited clinics located in six big cities and six rural provinces. From these samples, we isolated 1,291 cases of enteritis bacterial infection (4.8%). In the urban areas, 821 cases of bacterial infection (6.4%) were identified and, in the rural areas, 479 bacterial strains (3.3%) were isolated. Seasonal patterns were seen for diarrhea associated with S. aureus, E. coli and V. parahaemolyticus, while Salmonella and Shigella infections showed slight seasonal variation. We found that S. aureus and Salmonella were more frequently isolated from children and the elderly; however, the prevalence of E. coli, V. parahaemolyticus, and Shigella were similar in different age groups. Routine monitoring of these infections is considered a worthwhile means by which to elucidate their epidemiology and modes of transmission and ultimately to control them more effectively. Continuous laboratory-based surveillance for findings of enteritis bacterial infection should be emphasized in the prevention of these infections.