Dissemination of an antibiotic resistance plasmid in hospital patient flora

Improving cell and gene therapy safety and performance using next-generation Nanoplasmid vectors

The cell and gene therapy industry has employed the same plasmid technology for decades in vaccination, cell and gene therapy, and as a raw material in viral vector and RNA production. While canonical plasmids contain antibiotic resistance markers in bacterial backbones greater than 2,000 base pairs, smaller backbones increase expression level and durability and reduce the cell-transfection-associated toxicity and transgene silencing that can occur with canonical plasmids. Therefore, the small backbone and antibiotic-free selection method of Nanoplasmid vectors have proven to be a transformative replacement in a wide variety of applications, offering a greater safety profile and efficiency than traditional plasmids. This review provides an overview of the Nanoplasmid technology and highlights its specific benefits for various applications with examples from recent publications.

The 2017 Garrod Lecture: Genes, guts and globalization

The widespread use of antibacterial drugs over the last 70 years has brought immense benefits to human health at the price of increasing drug inefficacy. Antibacterial agents have a strong selective effect in both favouring resistant strains and allowing particular species and families of bacteria to prosper, especially in the healthcare setting. Whilst important Gram-positive bacterial pathogens such as Staphylococcus aureus and Streptococcus pneumoniae caused concern over the last 20 years because of the spread of antibiotic-resistant strains, Enterobacteriaceae have become the biggest challenge. They have very efficient mechanisms for genetic exchange, as illustrated by the emergence and rapid spread of CTX-M β-lactamases and the carbapenemases. The unique epidemiology of Enterobacteriaceae, with substantial numbers colonizing the mammalian gut and subsequent release into and spread in the environment, presents a significant threat to human health because of the high levels of exposure for the whole community. The use of antimicrobials in agriculture combined with global movements of people, animals and food, arising from worldwide industrialization, generates a diversity and level of resistance not seen previously. Control will require globally coordinated interventions similar to those needed to ameliorate climate change.

Chronic impacts of oxytetracycline on mesophilic anaerobic digestion of excess sludge: Inhibition of hydrolytic acidification and enrichment of antibiotic resistome

We evaluated the chronic impact of oxytetracycline (OTC) on performance and antibiotic resistance development during the mesophilic anaerobic digestion (AD) of antibiotic-containing biomass. Mesophilic AD was conducted in a completely stirred tank reactor by constantly feeding municipal excess sludge spiked with increasing concentrations of OTC (0-1000 mg L^-1) under a solid retention time of 20 days over a period of 265 days. Results showed that methane generation of mesophilic AD was inhibited when the OTC concentration in digested sludge was increased to around 18,000 mg kg^-1 (OTC dose, 1000 mg L^-1), due to the inhibition of fermenting and acidogenic bacteria. Metagenomic sequencing and high-throughput quantitative PCR analysis demonstrated that tetracycline resistance genes were the most dominant type (38.47-43.76%) in the resistome, with tetG, tetX, tetM, tetR, tetQ, tetO, and tetL as the dominant resistant subtypes throughout the whole experimental period. The relative abundance of these tet genes increased from 2.10 × 10^-1 before spiking OTC (OTC concentration in digested sludge, 8.97 mg kg^-1) to 2.83 × 10^-1 (p < 0.05) after spiking OTC at a dose of 40 mg L^-1 (OTC concentration in digested sludge, 528.52 mg kg^-1). Furthermore, mobile genetic elements, including integrons, transposons, and plasmids, were also enriched with the increase in OTC dose. Based on partial canonical correspondence analysis, the contributions of horizontal (mobile element alteration) and vertical (bacterial community shift) gene transfer to antibiotic resistome variation were 29.35% and 21.51%, respectively. Thus, considering the inhibition of hydrolytic acidification and enrichment of antibiotic resistome, mesophilic AD is not suggested to directly treat the biomass containing OTC concentration higher than 200 mg L^-1.

A Microbiologic Approach to the Investigation of Bacterial Nosocomial Infection Outbreaks

This article details the appropriate microbiologic support that is critical to the successful investigation of nosocomial infection problems. The infection control team must have ready access to microbiologic data, and the laboratory should retain epidemiologically relevant bacterial isolates. Investigation of epidemics is facilitated by precise identification of bacteria and careful antibiotic susceptibility testing. In some situations, biotyping, serotyping, phage typing, bacteriocin typing, and other specialized techniques may be required. Plasmid analysis may be useful in the investigation of nosocomial infection problems caused by antibiotic-resistant bacteria.

The world's microbiology laboratories can be a global microbial sensor network

The microbes that infect us spread in global and local epidemics, and the resistance genes that block their treatment spread within and between them. All we can know about where they are to track and contain them comes from the only places that can see them, the world's microbiology laboratories, but most report each patient's microbe only to that patient's caregiver. Sensors, ranging from instruments to birdwatchers, are now being linked in electronic networks to monitor and interpret algorithmically in real-time ocean currents, atmospheric carbon, supply-chain inventory, bird migration, etc. To so link the world's microbiology laboratories as exquisite sensors in a truly lifesaving real-time network their data must be accessed and fully subtyped. Microbiology laboratories put individual reports into inaccessible paper or mutually incompatible electronic reporting systems, but those from more than 2,200 laboratories in more than 108 countries worldwide are now accessed and translated into compatible WHONET files. These increasingly web-based files could initiate a global microbial sensor network. Unused microbiology laboratory byproduct data, now from drug susceptibility and biochemical testing but increasingly from new technologies (genotyping, MALDI-TOF, etc.), can be reused to subtype microbes of each genus/species into sub-groupings that are discriminated and traced with greater sensitivity. Ongoing statistical delineation of subtypes from global sensor network data will improve detection of movement into any patient of a microbe or resistance gene from another patient, medical center or country. Growing data on clinical manifestations and global distributions of subtypes can automate comments for patient's reports, select microbes to genotype and alert responders.

Biochemical phenotypes to discriminate microbial subpopulations and improve outbreak detection

Background

Clinical microbiology laboratories worldwide constitute an invaluable resource for monitoring emerging threats and the spread of antimicrobial resistance. We studied the growing number of biochemical tests routinely performed on clinical isolates to explore their value as epidemiological markers.

Methodology/Principal Findings

Microbiology laboratory results from January 2009 through December 2011 from a 793-bed hospital stored in WHONET were examined. Variables included patient location, collection date, organism, and 47 biochemical and 17 antimicrobial susceptibility test results reported by Vitek 2. To identify biochemical tests that were particularly valuable (stable with repeat testing, but good variability across the species) or problematic (inconsistent results with repeat testing), three types of variance analyses were performed on isolates of K. pneumonia: descriptive analysis of discordant biochemical results in same-day isolates, an average within-patient variance index, and generalized linear mixed model variance component analysis. Results: 4,200 isolates of K. pneumoniae were identified from 2,485 patients, 32% of whom had multiple isolates. The first two variance analyses highlighted SUCT, TyrA, GlyA, and GGT as “nuisance” biochemicals for which discordant within-patient test results impacted a high proportion of patient results, while dTAG had relatively good within-patient stability with good heterogeneity across the species. Variance component analyses confirmed the relative stability of dTAG, and identified additional biochemicals such as PHOS with a large between patient to within patient variance ratio. A reduced subset of biochemicals improved the robustness of strain definition for carbapenem-resistant K. pneumoniae. Surveillance analyses suggest that the reduced biochemical profile could improve the timeliness and specificity of outbreak detection algorithms.

Conclusions

The statistical approaches explored can improve the robust recognition of microbial subpopulations with routinely available biochemical test results, of value in the timely detection of outbreak clones and evolutionarily important genetic events.

Integrated Multilevel Surveillance of the World's Infecting Microbes and Their Resistance to Antimicrobial Agents

Microbial surveillance systems have varied in their source of support; type of laboratory reporting (patient care or reference); inclusiveness of reports filed; extent of microbial typing; whether single hospital, multihospital, or multicountry; proportion of total medical centers participating; and types, levels, integration across levels, and automation of analyses performed. These surveillance systems variably support the diagnosis and treatment of patients, local or regional infection control, local or national policies and guidelines, laboratory capacity building, sentinel surveillance, and patient safety. Overall, however, only a small fraction of available data are under any surveillance, and very few data are fully integrated and analyzed. Advancing informatics and genomics can make microbial surveillance far more efficient and effective at preventing infections and improving their outcomes. The world's microbiology laboratories should upload their reports each day to programs that detect events, trends, and epidemics in communities, hospitals, countries, and the world.

Removal of ciprofloxacin in simulated digestive media by activated charcoal entrapped within zinc-pectinate beads

Beads made of a zinc-pectinate matrix containing activated charcoal were designed for the adsorption of colonic residual antibiotics responsible of the emergence of resistance. Bead stability was shown to correlate with bead zinc content, 0.08 mg/mg being the minimal amount of zinc that protects the egg-box structure against total disintegration. Moreover, the stability in simulated gastro-intestinal media was shown to be related to the composition of the incubation medium. Indeed, gastric medium was shown to extract a large amount of zinc inducing an early disintegration of the beads in the intestinal medium, making necessary their protection by gastro-resistant capsules. Simulated intestinal medium buffered by phosphate was not adapted for the disintegration studies since the formation of a zinc phosphate precipitate on beads surface enhances their resistance to further degradation by pectinases contained in colonic medium. On the other hand, beads incubated in HEPES were stable in intestinal medium and nicely degraded by pectinases contained in simulated colonic medium. Despite this stability, coating with Eudragit RS was needed to prevent the early adsorption of antibiotics in intestinal medium. Adsorption studies in the simulated colonic medium show that the adsorption capacity of activated charcoal is not modified after its encapsulation within pectin beads making the elimination of ciprofloxacin reaching the colon clinically feasible.

Acquisition of antibiotic resistance plasmids by enterohemorrhagic Escherichia coli O157:H7 within rumen fluid

The emergence of antibiotic resistance among important foodborne pathogens like Escherichia coli O157:H7 has become an important issue with regard to food safety. In contrast to the case for Salmonella, antibiotic resistance has been slow in its development in E. coli O157:H7 despite the presence of mobile antibiotic resistance genes in other E. coli organisms that inhabit the same animal host. We set out to determine if rumen fluid influences the transfer of plasmid-mediated, antibiotic resistance to E. coli O157:H7. A commensal E. coli strain from a dairy cow was transformed with conjugative R plasmids and served as the donor in matings with naladixic acid-resistant E. coli O157:H7. R plasmids were transferred from the donor E. coli strain to E. coli O157:H7 in both Luria-Bertani (LB) broth and rumen fluid. R plasmids were transferred at a higher frequency to E. coli O157:H7 during 6 h of incubation in rumen fluid at rates comparable to those in LB broth, indicating that conditions in rumen fluid favor the transfer of the plasmids to E. coli O157. This finding suggests that the cow's rumen is a favorable environment for the genetic exchange of plasmids between microflora and resident E. coli O157:H7 in the bovine host.

Increasing threat of Gram-negative bacteria

The widespread use of broad-spectrum antibiotics has led to emergence of antibiotic-resistant strains of many Gram-negative organisms. This problem is particularly serious in critically ill patients, especially those with ventilator-associated pneumonia. Extensive antibiotic resistance has developed in Gram-negative bacteria, due both to innate resistance in some species and the fact that they are highly adept at acquiring antibiotic-resistant determinants from each other. Antibiotic resistance develops through the following three basic mechanisms: alteration of the drug target, prevention of drug access to the target (including actively removing the drug from the bacteria), and drug inactivation. Certain Gram-negative microorganisms are particular problems in the intensive care unit, including Pseudomonas aeruginosa, Acinetobacter spp., Stenotrophomonas maltophilia, and the Enterobacteriaceae. The combination of an increasing population at risk, and the natural virulence and adaptability of Gram-negative bacteria guarantees that critical care physicians will face a persistent and increasing challenge from these pathogens.

Antibiotic resistance in oral/respiratory bacteria

In the last 20 years, changes in world technology have occurred which have allowed for the rapid transport of people, food, and goods. Unfortunately, antibiotic residues and antibiotic-resistant bacteria have been transported as well. Over the past 20 years, the rise in antibiotic-resistant gene carriage in virtually every species of bacteria, not just oral/respiratory bacteria, has been documented. In this review, the main mechanisms of resistance to the important antibiotics used for treatment of disease caused by oral/respiratory bacteria--including beta-lactams, tetracycline, and metronidazole--are discussed in detail. Mechanisms of resistance for macrolides, lincosamides, streptogramins, trimethoprim, sulfonamides, aminoglycosides, and chloramphenicol are also discussed, along with the possible role that mercury resistance may play in the bacterial ecology.

Role of molecular epidemiology in infection control

Molecular typing methods have enabled infection control personnel to investigate outbreaks and endemic nosocomial infections more quickly and thoroughly than they could have with basic epidemiologic and microbiologic methods. This article reviews molecular typing methods that have been used successfully in the practice of hospital epidemiology. Included is an explanation of the basic principles of these methods and a description of their strengths and weaknesses.

Use of ribotyping in epidemiological surveillance of nosocomial outbreaks

Over the past few years, genotypic methods based on the study of bacterial DNA polymorphism have shown high discriminatory power for strain differentiation and superiority over most phenotypic methods commonly available in the clinical microbiology laboratory. Some of the methods used, however, required either a high level of technology and sophisticated equipment (e.g., pulsed-field gel electrophoresis) or species-specific reagents of restricted availability (randomly cloned DNA probes or gene-specific probes). Because ribotyping uses a universal probe (rRNA) and is a rather simple technology, particularly since the advent of nonradioactive labelling systems, it has been widely used for strain differentiation of most bacterial species involved in nosocomial outbreaks. In vitro and in vivo stability of the markers studied has been demonstrated. Although there may be limitation to this approach, ribotyping was found to be highly discriminative, particularly for typing members of the family Enterobacteriaceae, Pseudomonas cepacia, and Xanthomonas maltophilia. In many cases, it has improved the understanding of the mechanism of nosocomial acquisition of organisms by allowing a distinction between endogenous and exogenous infections. Among exogenous infections, it has distinguished between individual and epidemic strains, thus differentiating cross-infection from independent acquisition.

Genetic and molecular R-plasmid analysis of Enterobacteriaceae hospital strains at Children's Hospitals of the former USSR

R-plasmids from Enterobacteriaceae clinical strains, mainly Klebsiella and Serratia, isolated at different neonatal and children's hospitals of different cities of the former USSR for 10 years, were studied for their possible influence on the bacterial host phenotype. Hospital R-plasmids of stable inheritance persisted in hospitals from 2 to 7 years and were disseminated among strains of different genera (Klebsiella, Serratia, Enterobacter) and among different units. The data showed a possibility of long-term molecular rearrangements of R-plasmids in the hospital settings and an acquisition of genetic determinants encoding enterotoxin production. A novel R-plasmid encoding cytotoxicity to HEp-2 cells involved in two nosocomial outbreaks due to K. pneumoniae strains was reported. K. pneumoniae population heterogeneity was evaluated by using the plasmid parameters of strains. Their heterogeneity of a bacterial population was significantly lower during nosocomial outbreaks than in interepidemic periods.

Typing of strains from a single-source outbreak of Pseudomonas pickettii

Plasmid profiles, genome restriction fragment polymorphisms, carbohydrate oxidation-fermentation reactions, methylumbelliferyl substrate hydrolysis patterns, antimicrobial susceptibilities, and results obtained with the Biolog GN biochemical substrate kit were used to type 19 common-source, but mixed-biotype, outbreak strains and one epidemiologically distinct strain of Pseudomonas pickettii. Biotyping with conventional and methylumbelliferyl substrates failed to distinguish between strains. Plasmid profile testing was found to be inconsistent and not reproducible. The Biolog GN kit allowed greater strain differentiation than restriction fragment polymorphism did (12 biotypes versus 5 biotypes); antimicrobial susceptibility testing yielded 4 biotypes, and oxidation-fermentation tests gave 3 biotypes. Oxidation-fermentation results were consistent with restriction fragment polymorphs in all but 1 of the 20 strains tested. For ease of typing, comprehensive typeability, and reproducibility, oxidation-fermentation tests should be performed initially and followed if necessary by restriction fragment polymorph analysis for the elucidation of P. pickettii infection outbreaks.

Molecular typing of Salmonella enterica subsp. enterica serovar Wien by rRNA gene restriction patterns

Analysis of digested DNA from 40 Salmonella enterica subsp. enterica serovar Wien isolates revealed five different rRNA gene restriction patterns for HindIII (H1 to H5) and five for PstI (P1 to P5). The isolates had been selected on the basis of the year of isolation, the geographic origin and the antibiotic resistance pattern and were distinguished as follows: a) 13 pre-epidemic isolates from different French towns in 1958-69 and from Senegal in 1968; b) 7 epidemic isolates from Algiers in 1969; c) 20 post-epidemic isolates from different French and Italian towns in 1970-90. Three different rRNA patterns (H1P1, H3P3 and H4P4) were observed among the pre-epidemic isolates. Conversely, the epidemic isolates, which were characterized by the previously described large antibiotic resistance patterns and by the presence of 1.3 and 80-109 MDa plasmids, belonged to the same H1P1 ribotype. All but two post-epidemic isolates were of the H1P1 ribotype. The determination of rRNA gene restriction patterns together with the plasmid content proved to be useful for a better characterization of the serovar Wien endemic and epidemic isolates.

Novel and emerging mechanisms of antimicrobial resistance in nosocomial pathogens

Nosocomial pathogens frequently are resistant to antimicrobial agents. Although methicillin-resistant strains of Staphylococcus aureus continue to be a major problem in many hospitals, several new types of resistance determinants have been noted among organisms causing hospital-acquired infections. The mechanisms include extended spectrum beta-lactamases in gram-negative bacilli; resistance to beta-lactams, glycopeptides, and high levels of aminoglycosides among enterococci; quinolone resistance in isolates of methicillin-resistant S. aureus; and the spread of multiple resistance genes simultaneously in gram-negative organisms via Tn21-related genetic elements. These novel mechanisms of resistance complicate the treatment of nosocomial infections by limiting the number of effective antimicrobial agents available to the clinician. It is important for infection control practitioners and microbiologists to work together to detect and control the spread of resistant pathogens in the hospital setting.

Aminoglycoside resistance and aminoglycoside usage: ten years of experience in one hospital

For 10 years the 700-bed Minneapolis Veterans Affairs Medical Center has conducted a policy of carefully controlled aminoglycoside usage and monitoring of resistance of over 25,000 aerobic and facultative gram-negative bacillary isolates to the aminoglycosides. On two occasions during the 1980s, our experience of introducing amikacin at a high level of usage was associated with a significant reduction in resistance to gentamicin and tobramycin among gram-negative bacilli. Rapid reintroduction of gentamicin usage in 1982 after the first amikacin period was associated with a significant and rapid increase in gentamicin and tobramycin resistance. However, in 1986, gentamicin was again reintroduced to this institution at an initially modest level, and the percentage of usage of gentamicin was gradually increased over a 15-month period without a significant change in resistance to gentamicin, tobramycin, or amikacin while maintaining an overall 68% gentamicin usage and 30% amikacin usage. Aminoglycoside usage (measured as patient days) rose steadily from under 2,000 patient days per quarter in 1980 and 1981 to over 3,000 days per quarter in 1985. Since 1985, usage has declined to under 2,500 patient days per quarter in 1990. This usage rise and fall occurred during a steadily declining daily patient census that was 590 in 1980 and 465 in 1989. A move to a new hospital building in June 1988 was associated with an additional significant decline in resistance to all aminoglycosides (P less than 0.05), continuing a trend that was evident for the year preceding the move. Resistance to aminoglycoside antibiotics is now at the lowest level in 10 years at this institution, with only one gram-negative organism, Pseudomonas aeruginosa, that exhibits more than 5% resistance to gentamicin and no gram-negative species that are more than 5% resistant to amikacin and tobramycin.

Molecular epidemiology of TEM-3 (CTX-1) beta-lactamase

A total of 33 clinical isolates encoding TEM-3 (CTX-1) from four French hospitals were studied. The strains belonged to seven species, Klebsiella pneumoniae (n = 24), Escherichia coli (n = 3), Serratia marcescens (n = 2), Citrobacter freundii (n = 1), Enterobacter aerogenes (n = 1), Enterobacter cloacae (n = 1), and Klebsiella oxytoca (n = 1). All the strains harbored an Inc7 or M self-transferable plasmid with a size of approximately 85 kilobases. The plasmids had closely related EcoRI, HincII, HindIII, and PvuII restriction endonuclease-generated patterns and conferred resistance to all beta-lactams, except cephamycins and imipenem; to tetracycline, because of the presence of the genes blatem-3 and tetC, respectively, as determined by hybridization with specific probes; and to sulfonamide. Depending on the presence or absence and level of expression of the genes aacA4, aadA, and dfrI and of insertion element IS15, four types of plasmids could be distinguished. Plasmid pCFF04, the prototype plasmid encoding TEM-3, was widespread and appeared, by Southern hybridization, as the progenitor of the other types of replicons. The plasmid epidemic responsible for dissemination of TEM-3 in clinical isolates of members of the family Enterobacteriaceae may have originated in S. marcescens since pCFF04 was first detected in this species.

Detection and interspecies-transformation of a beta-lactamase-encoding plasmid from Pasteurella haemolytica

Pasteurella haemolytica-cultures, isolated from cattle with respiratory diseases, were investigated for their biotype, serotype, antimicrobial resistance and plasmid content. A plasmid encoding a beta-lactamase could be demonstrated in 9 of 19 Pasteurella haemolytica-cultures. These 9 cultures, all belonging to biotype A and serotype 1, were resistant to ampicillin, carbenicillin, penicillin G and ticarcillin. The plasmid of the respective cultures proved to be identical upon Southern blot hybridization. It could be transformed into Escherichia coli 490 A where it expressed again a beta-lactamase-activity.

Isolation and interspecies-transfer of a plasmid from Pasteurella multocida encoding for streptomycin resistance

A plasmid encoding streptomycin-resistance could be detected in 13 of 32 Pasteurella multocida-cultures isolated from cattle and swine. The plasmid of these cultures proved to be similar upon Southern blot hybridization. It could be transformed into Escherichia coli 490A, where it also expressed streptomycin resistance.

Resistance-pattern-analysis--a step toward predictable differentiated antibiotic therapy

The Resistance-Pattern-Analysis (RPA)-the procedure will be described- makes possible a comparison of susceptibility test results of different antibiotics independent of patient and test related factors. Using two examples, the comparative assessment of a more recent antibiotic with well-tried older antibiotics and the selection of antibiotics for an interventive therapy, whereby the pathogen being unknown the therapy is based upon the probable pathogen, the expected susceptibility and the localization of the infection the practicability will be illustrated. A RPA of 1526 bacterial isolates was carried out using aztreonam, gentamicin and amikacin. Aztreonam was superior to amikacin against all species tested. In comparison to gentamicin, aztreonam showed the best results against Pseudomonadaceae. Using common combinations of antibiotics for the initial interventive therapy the possible use of RPA for a cost-risk-analysis from a medical microbiological viewpoint will be demonstrated.

Aminoglycoside resistance patterns in Turkey

Resistance of gram-negative aerobic bacteria to aminoglycoside antibiotics differs by region and country. It is known that 54% of gram-negative bacilli in Turkey are resistant to gentamicin, 32% to netilmicin, 35% to tobramycin, and only 0.9% to amikacin. Resistance to these antibiotics is generally caused by aminoglycoside-modifying enzymes. The resistance mechanisms of 300 aminoglycoside-resistant gram-negative bacteria were evaluated by determination of susceptibility to selected aminoglycosides. Comparison of strains isolated from community acquired infections and hospital acquired infections was made. Of the strains from community, 45.4% had an aminoglycoside resistance pattern indicative of 2''-adenyltransferase [ANT(2'')]. This was found in 44.4% of the hospital isolates. In both groups the second common enzyme was the 3-acetyltransferase [AAC(3)-II], in 20.8% and 23.3% respectively. Overall, most strains had an aminoglycoside resistance pattern indicative of ANT(2''), followed by AAC(3)-II and AAC(3)-I. Among bacteria tested, AAC(3)-II was the most common enzyme in Pseudomonas aeruginosa. The results of this study suggest that local antibiotic prescribing patterns play an important role in regional resistance mechanisms.

Comparison of a novel trimethoprim-sulfamethoxazole-containing medium (XT80) with kanamycin agar for isolation of antibiotic-resistant organisms from stool and rectal cultures of marrow transplant patients

A new medium (XT80) containing trimethoprim-sulfamethoxazole (TMP-SMZ) was characterized and compared with kanamycin-containing tryptic soy agar (KA) for the recovery of multiply resistant organisms (MRO) in rectal and stool cultures. Cultures from 151 patients hospitalized for bone marrow transplantation were screened for MRO. A total of 366 MRO were recovered from 702 cultures on 94 patients during a 6-month period. XT80 detected more gram-negative bacilli and Corynebacterium spp. than KA. Detection of Staphylococcus spp. was equivalent for the two media. Multiple-antibiotic resistance, defined as resistance to three or more classes of antibiotics, was confirmed by standard agar disk diffusion susceptibility testing. Growth on XT80 correctly identified heteroresistant strains of methicillin-resistant Staphylococcus spp. XT80 more rapidly detected thymidine-dependent mutants of Staphylococcus spp. and members of the family Enterobacteriaceae. Lipophilic Corynebacterium spp., including Corynebacterium group JK, also were more readily detected with XT80. TMP-SMZ given as prophylaxis against Pneumocystis carinii infection exerts a selective pressure on organisms that colonize immunocompromised patients and appears to select for colonization with MRO. Colonization with MRO preceded infection for 94% of 36 patients who developed bacteremia. XT80 is a useful screening tool; growth on this medium correlates closely with resistance to TMP-SMZ and is as accurate a predictor as KA for the carriage of MRO.

New microbiological techniques for hospital epidemiology

Infection control teams rely on microbiology laboratories for accurate, reproducible data to trace the spread of microorganisms in the hospital. Since few problems are recognized immediately, laboratories should save important nosocomial pathogens so that outbreak strains will be available for analysis by more sophisticated techniques, particularly since automation has reduced the amount of epidemiologically useful data generated by routine procedures. Traditional supplemental reference procedures include phage typing, biotyping, serotyping and bacteriocin typing. Recently, analysis of antibiotic resistance determinants has provided the hospital epidemiologist with additional tools. Resistant strains have been characterized by their production of specific antibiotic inactivating enzymes. Agarose gel electrophoresis and restriction endonuclease analysis of plasmid DNA have permitted precise characterization of nosocomial strains, and the spread of antibiotic resistance genes can now be followed by sensitive and specific DNA probes. DNA probes also show promise for distinguishing nosocomial strains bearing known virulence factors from strains with less pathogenic potential. Molecular genetics techniques have found an additional role in elucidating the epidemiology of nosocomial viruses, especially the herpesviruses.

Prevalence of colonization with antibiotic resistant gram-negative bacilli in a nursing home care unit: the importance of cross-colonization as documented by plasmid analysis

A prevalence study was carried out on a 100-bed Veterans Administration nursing home care unit to determine the extent of colonization with gentamicin-resistant gram-negative bacilli (GRGNB). Hand cultures of 12 employees and 17 environmental cultures were negative. Twenty-six of 86 (30%) patients were colonized with 49 GRGNB. Sixteen patients (19%) had urinary colonization. Multivariate analysis revealed significant associations between rectal or perineal colonization (P less than 0.01), and the presence of a urinary device (82% condom catheters) (P less than 0.05), with urinary colonization. The most common isolates were Providencia stuartii (20), Escherichia coli (nine) and Klebsiella pneumoniae (nine). Twenty-six of 49 isolates carried plasmids. Restriction endonuclease digestion of plasmid DNA was performed for 21. Cross-colonization, as defined by the presence of the identical species with the identical restriction endonuclease digestion profile of purified plasmid DNA found in different patients, was observed for eight of 21 (38%) strains. All were geographically clustered. No strains could transfer gentamicin-resistance by conjugation and only two plasmids could transform our E coli recipient to gentamicin resistance. One E coli plasmid was identical to two Citrobacter freundii plasmids and a P stuartii plasmid isolated from three different patients. This 105 kb plasmid is conjugative and encodes resistance to ampicillin, carbenicillin, tetracycline, and sulfonamides. Thus, 57% of strains were cross-colonizing or contained identical R-plasmids. Southern hybridization using a 1 kb TEM-1 gene probe demonstrated sequences homologous to this probe in five of five nursing home plasmids examined.(ABSTRACT TRUNCATED AT 250 WORDS)

Diversity of determinants encoding carbenicillin, gentamicin, and tobramycin resistance in nosocomial Pseudomonas aeruginosa

Plasmid pFMH1010, an 89-megadalton R plasmid, is endemic among members of the family Enterobacteriaceae at Hines Veterans Administration Hospital, Hines, Ill. It encodes resistance to nine antibiotics, including resistance to carbenicillin (Cb), gentamicin (Gm), and tobramycin (Tm). Pseudomonas aeruginosa strains resistant to carbenicillin, gentamicin, and tobramycin were isolated from five patients at Hines Veterans Administration Hospital from whom Serratia marcescens strains harboring pFMH1010 were also obtained. The P. aeruginosa strains were investigated to determine whether their Cb, Gm, and Tm characteristics derived from pFMH1010. One of the isolates, Ps559, was shown by Southern hybridization to contain approximately 76% of pFMH1010. Several lines of evidence suggested that the pFMH1010 sequences in Ps559 are integrated in the chromosome. Southern hybridization also demonstrated that the beta-lactam resistance of pFMH1010 is most probably due to the presence of sequences homologous with Tn3 and that these sequences are retained in Ps559. In two other Pseudomonas isolates, resistance to carbenicillin, gentamicin, tobramycin, and kanamycin was encoded by R plasmids unrelated to pFMH1010. In the last two isolates, resistance to gentamicin and tobramycin and several other antibiotics appeared to be chromosomally encoded, and it was rescuable from one of these strains by RP4-mediated mobilization.

Prevalence and mechanisms of aminoglycoside resistance. A ten-year study

Aminoglycoside resistance was monitored at St. Thomas' Hospital from 1975 to 1984. Gentamicin resistance had appeared in a number of species by 1975, but remained rare (less than 1 percent of isolates) in Escherichia coli throughout the study period. Gentamicin-resistant Klebsielleae had become fairly common (8 percent of isolates) by 1977, but little change has subsequently occurred in their frequency of isolation. Serratia species are not frequently isolated; gentamicin resistance in these organisms was not observed until 1979. Since then, 10 to 20 percent of isolates have been found to be resistant. Except for Providencia, most isolates of which were gentamicin-resistant, less than 5 percent of the Enterobacteriaceae isolated were found to be resistant to gentamicin during the 10-year period. Throughout the study, approximately 5 percent of the Pseudomonas aeruginosa isolates were resistant to gentamicin. Less than 5 percent of the isolates of Acinetobacter were resistant to gentamicin before 1979, at which time 40 percent were found to be resistant; subsequently, gentamicin resistance among these organisms has become somewhat less common. On the whole, tobramycin resistance has mirrored gentamicin resistance. However, before 1979, most gentamicin-resistant Klebsielleae isolates had retained susceptibility to tobramycin, as had most gentamicin-resistant isolates of Acinetobacter and P. aeruginosa. Amikacin resistance has remained very unusual in all organisms, apart from non-aeruginosa Pseudomonas species. Until 1977, nearly all the resistance among Enterobacteriaceae was attributable to AAC(3)-I, except for that caused by AAC(2') production in Providencia and the non-enzymatic resistance observed in E. coli. However, more recently, AAC(3)-II and AAD(2'') have become the most common mechanisms of resistance. The resistance of most gentamicin-resistant isolates of P. aeruginosa from 1974 to 1977 was attributable to non-enzymatic mechanisms; subsequently, such resistance was more often caused by AAC(3)-I, AAC(6'), or AAD(2''). Gentamicin resistance first appeared in Staphylococcus aureus in 1976, after which about 1 to 2 percent of the isolates from hospitalized patients were found to be resistant, mostly because of production of AAC(6') and APH(2'').

Review of epidemic aminoglycoside resistance worldwide

Epidemic aminoglycoside resistance may be caused by the spread of a species with distinctive chromosomal genes (e.g., Pseudomonas aeruginosa), or it may be due to the dissemination of plasmids or transposons between genera. Although strains of P. aeruginosa resistant to aminoglycosides because of impermeability may cause nosocomial outbreaks, most of the acute increases in aminoglycoside resistance are due to the spread of inactivating enzymes by plasmids. The index species for intergeneric outbreaks is usually Klebsiella pneumoniae carrying the ANT(2") or AAC(3) gene; however, the distribution of resistance varies greatly by location and species. The AAC(6')-I gene is most common in Serratia marcescens and in East Asian isolates of other species, whereas the AAC(3) gene is common in Chile. In the United States, the ANT(2") and AAC(3) genes are particularly common among Enterobacteriaceae, except for Proteus and Providencia, which often carry the AAC(2') gene. The most common patterns of epidemic resistance lead to the inactivation of gentamicin and, less frequently, tobramycin, but only rarely affect amikacin.

Serratia marcescens infections

The recognition of serratia as an opportunistic human pathogen can be dated from 1959, when the microorganism entered the family ofEnterobacteriaceae,with features recognizable in the clinical laboratory and related to theKlebsiella/Enterobactergroup. Since then, physicians have been challenged to establish the significance of isolation of serratia from a clinical specimen.

Molecular evolution, species distribution, and clinical consequences of an endemic aminoglycoside resistance plasmid

During the first 6 years after appearing in one hospital, a 92-kilobase conjugative plasmid, pBWH1, which encoded resistance to chloramphenicol and sulfonamides and determined TEM-1 beta-lactamase and 2''-aminoglycoside nucleotidyltransferase, underwent a variety of molecular changes. It was most prevalent initially in isolates of Klebsiella pneumoniae, then in isolates of Serratia marcescens, and finally, after nearly disappearing, in isolates of Enterobacter cloacae. Evolutionary changes in the plasmid did not account for its shifts in species distribution, since the original molecule was found in isolates of each species. The late resurgence of pBWH1 occurred after a copy of its original molecule entered a distinctive ornithine decarboxylase-negative strain of E. cloacae, new to the hospital. The resulting transconjugant strain, chromosomally resistant to topical silver salts and to cephalosporins, and with the addition of pBWH1-encoded aminoglycoside resistance, spread in the hospital by causing an outbreak of sepsis in the burn unit, where these were commonly used antibacterial agents. Thus, an endemic plasmid became prevalent in a new host species because one of its genes supplemented the fitness of an uncommon strain of the species for a particular clinical niche.

Hospital distribution, persistence, and reintroduction of related gentamicin R plasmids

A single plasmid clone was predominantly responsible for gentamicin resistance at the Minneapolis Veterans Administration Medical Center (MVAMC) for 9 years, although two unrelated R plasmids were found. Epidemiological data and restriction endonuclease analysis of 25 plasmid isolates suggested that the clonally derived plasmid population had persisted at the hospital. However, one case of reintroduction of the original epidemic plasmid from a hospital in another state was documented 4 years after the introduction of the original plasmid to the MVAMC. Resistance by the clonally derived plasmid population was not localized geographically within the MVAMC but rather was a hospital-wide problem. Furthermore, previously described classes of DNA rearrangement of the original plasmid were also widely disseminated in the hospital, implying that spread of strains bearing index-related plasmids was relatively unimpeded within the MVAMC despite extensive barrier isolation and cohorting measures. Potential environmental reservoirs of the plasmids were identified in hospital sinks and drains, but their relation to continued patient infection is not known.

Plasmid-encoded amikacin resistance in multiresistant strains of Klebsiella pneumoniae isolated from neonates with meningitis

Two multiresistant Klebsiella pneumoniae strains isolated from cerebrospinal fluid of human neonates were analyzed for their plasmid content. Two of the plasmids harbored by these strains, pJHCMW1 (11 kilobase pairs) and pJHCMW4 (75 kilobase pairs), carried genetic determinants for amikacin resistance. These plasmids also encoded resistance to kanamycin, tobramycin, and ampicillin which could be transferred to Escherichia coli by conjugation. Extracts from transconjugant derivatives carrying pJHCMW4 produced an acetyltransferase activity that acetylated all three aminoglycosides. Transconjugant derivatives carrying pJHCMW1 encoded both acetylating and phosphorylating activities. Southern blot hybridization analysis indicated considerable DNA homology between these two plasmids.

Genetic and physical characterization of IncM plasmid pBWH1 and its variance among natural isolates

We present a genetic and physical characterization of the IncM plasmid pBWH1. A physical map was constructed for the enzymes EcoRI, BamHI, SalI, BglII, HindIII, MstII, and XhoI. A series of deletions and a series of subclones of pBWH1 were constructed and used to determine the locations on this map of the transfer region; the replication region; and the genes determining resistance to beta-lactams, chloramphenicol, the sulfonamides, and gentamicin. We compared 51 different isolates, including isolates which had lost individual antibiotic resistances or the transfer phenotype, and showed that variations occurred in all regions of the plasmid genome. Frequently, correlations could be made between phenotypic variation and variation of the EcoRI fragments which contained the gene determining that phenotype.

Intercontinental spread of a new antibiotic resistance gene on an epidemic plasmid

Bacteria of different genera isolated at nine medical centers in different parts of the United States and at one center in Venezuela during the first decade of gentamicin usage carried the gentamicin resistance gene 2"-aminoglycoside nucleotidyltransferase on the same transferable plasmid. Such widespread dissemination of a newly observed resistance gene on one plasmid suggests that a new resistance gene may emerge once on a single plasmid, which then carries it to other centers and other plasmids. The resistance gene might, therefore, be contained if detected early.

Molecular analysis of multiple-resistance plasmids transferred from gram-negative bacteria isolated in a urological unit

Forty-one isolates of multiply resistant gram-negative bacteria causing infection in a urological unit of a Dublin hospital were collected during a 6-month period. Twenty-one isolates transferred multiple resistance to an Escherichia coli K-12 recipient in liquid matings. Serratia marcescens, Proteus morganii, Proteus vulgaris, and E. coli isolates harbored similar 120-megadalton IncC plasmids, whereas Enterobacter cloacae strains transferred a 160-megadalton plasmid of a different Inc group. Southern hybridization experiments were performed with purified fragments cloned from one IncC plasmid as probes. They were hybridized to plasmid sequences in total cellular DNA extracts, showing that the IncC plasmids were very closely related. This suggests that the same plasmid has transferred to different bacterial species in the hospital environment.

Comparison of aminoglycoside resistance patterns in Japan, Formosa, and Korea, Chile, and the United States

The resistance mechanisms of more than 2,000 aminoglycoside-resistant gram-negative aerobic bacteria were estimated by a method that assigned a biochemical mechanism based on susceptibility to selected aminoglycosides. Strains from hospitals in Japan, Formosa, and Korea (the Far East) were compared with strains from Chile and the United States. Of the strains from Chile, 90% had an aminoglycoside resistance pattern indicative of the 3-N-acetyltransferase [AAC(3)-V] enzyme. Of the strains from the Far East, 78% had susceptibility patterns suggesting the presence of AAC(6') enzymes. In contrast, strains from the United States had a wider variety of resistance mechanisms including 2''-O-adenylyltidyltransferase [ANT(2'')], AAC(3), AAC(6'), and AAC(2'). Reflecting these differences in resistance patterns, the frequencies of resistance to gentamicin, tobramycin, dibekacin, and amikacin in strains from the United States were different from those in strains from the Far East. These differences seem to be correlated with different aminoglycoside usage in the two regions. In the United States, where gentamicin was the most widely used aminoglycoside, 92% of the strains were resistant to gentamicin, 81% were resistant to dibekacin, and 8.8% were resistant to amikacin. In the Far East, dibekacin and kanamycin were widely used in the past and more recently amikacin has been frequently used. Of the strains from this region, 99% were resistant to dibekacin, 85% were resistant to gentamicin, and 35% were resistant to amikacin.

Aminoglycoside resistance in gram-negative bacilli during increased amikacin use. Comparison of experience in 14 United States hospitals with experience in the Minneapolis Veterans Administration Medical Center

Resistance to amikacin, gentamicin, and tobramycin was surveyed prospectively during controlled aminoglycoside usage in 14 hospitals. Following an initial baseline period (minimum, three months) during which gentamicin use predominated, gentamicin and tobramycin were placed on restrictive control, establishing amikacin as the aminoglycoside of general use (86 percent of total aminoglycoside usage). During an average of 35 months' restriction of gentamicin and tobramycin, significant reductions in gram-negative resistance to gentamicin (8.4 to 7.0 percent, p less than 0.001) and tobramycin (6.0 to 5.3 percent, p less than 0.01) were observed. The most significant decreases in resistance to gentamicin and tobramycin (p less than 0.001) were found for Pseudomonas aeruginosa, Klebsiella species, Serratia species, and Proteus species. Amikacin resistance among gram-negative bacilli was observed to increase marginally from 1.4 to 1.7 percent (p less than 0.05) during the surveillance period, primarily due to a significant increase in resistance among P. aeruginosa (3.0 to 3.9 percent, p = 0.05). These data were compared with data from a similar surveillance program at the 700-bed Minneapolis Veterans Administration Medical Center. Over a period of 54 months, both gentamicin and tobramycin resistance decreased significantly when amikacin was used (p less than 0.001), then increased with reintroduction of gentamicin (p less than 0.05), and decreased significantly with reintroduction of amikacin (p less than 0.001). Despite predominant amikacin use for a total of 38 months, amikacin resistance did not increase and actually decreased significantly (p less than 0.05) in the last 12 months.

Comparison of three DNA hybridization methods for detection of the aminoglycoside 2"-O-adenylyltransferase gene in clinical bacterial isolates

Two rapid DNA hybridization methods in which whole-cell lysates fixed to nitrocellulose were used were compared with Southern hybridization of purified plasmid or chromosomal DNA for the ability to identify the 2"-O-adenylyltransferase [ANT(2")] gene in 42 enzymatically defined isolates of gram-negative bacilli. A DNA restriction fragment isolated from an ANT(2") gene cloned into pBR322 and radiolabeled with 32P was used as the probe in all three procedures. Under conditions of high stringency, agreement was obtained between the Southern hybridization method and detection of the ANT(2") enzyme by the phosphocellulose paper binding assay or resistance phenotype in 39 of the 42 strains tested. By using these characterized strains, colony hybridization was shown to be unsatisfactory as a rapid technique for detecting the ANT(2") gene, due to the high number of false-positive and -negative signals obtained. Compared with Southern hybridization, however, spot hybridization (SPH) proved highly reliable for detecting the ANT(2") gene in both members of Enterobacteriaceae and Pseudomonas aeruginosa harboring R factors ranging in size from 23 to 150 kilobases. The relatively low copy number of the 150-kilobase plasmids decreased the sensitivity of SPH, necessitating a minimum cell density of 5 X 10(6) cells per spot. SPH proved to be a very useful method for rapidly screening large numbers of clinical isolates for this resistance determinant.