Use of low-frequency-cleavage restriction endonucleases for DNA analysis in epidemiological investigations of nosocomial bacterial infections

Pulsotype Diversity of Clostridium botulinum Strains Containing Serotypes A and/or B Genes

Clostridium botulinum strains are prevalent in the environment and produce a potent neurotoxin that causes botulism, a rare but serious paralytic disease. In 2010, a national PulseNet database was established to curate C. botulinum pulsotypes and facilitate epidemiological investigations, particularly for serotypes A and B strains frequently associated with botulism cases in the United States. Between 2010 and 2014 we performed pulsed-field gel electrophoresis (PFGE) using a PulseNet protocol, uploaded the resulting PFGE patterns into a national database, and analyzed data according to PulseNet criteria (UPGMA clustering, Dice coefficient, 1.5% position tolerance, and 1.5% optimization). A retrospective data analysis was undertaken on 349 entries comprised of type A and B strains isolated from foodborne and infant cases to determine epidemiological relevance, resolution of the method, and the diversity of the database. Most studies to date on the pulsotype diversity of C. botulinum have encompassed very small sets of isolates; this study, with over 300 isolates, is more comprehensive than any published to date. Epidemiologically linked isolates had indistinguishable patterns, except in four instances and there were no obvious geographic trends noted. Simpson's Index of Diversity (D) has historically been used to demonstrate species diversity and abundance within a group, and is considered a standard descriptor for PFGE databases. Simpson's Index was calculated for each restriction endonuclease (SmaI, XhoI), the pattern combination SmaI-XhoI, as well as for each toxin serotype. The D values indicate that both enzymes provided better resolution for serotype B isolates than serotype A. XhoI as the secondary enzyme provided little additional discrimination for C. botulinum. SmaI patterns can be used to exclude unrelated isolates during a foodborne outbreak, but pulsotypes should always be considered concurrently with available epidemiological data.

Molecular Epidemiology of Mycobacterium tuberculosis Isolates in 100 Patients With Tuberculosis Using Pulsed Field Gel Electrophoresis

BACKGROUND

Tuberculosis (TB) is a widespread infectious disease. Today, TB has created a public health crisis in the world. Genotyping of Mycobacterium tuberculosis isolates is useful for surveying the dynamics of TB infection, identifying new outbreaks, and preventing the disease. Different molecular methods for clustering of M. tuberculosis isolates have been used.

OBJECTIVES

During a one year study of genotyping, 100 M. tuberculosis isolates from patients referred to Pasteur Institute of Iran were collected and their genotyping was accomplished using pulsed field gel electrophoresis (PFGE) method.

MATERIALS AND METHODS

Identification of all M. tuberculosis isolates was accomplished using standard biochemical and species-specific polymerase chain reaction (PCR) methods. Antibiotic susceptibility tests were performed using proportional method. After preparing PFGE plaques for each isolate of M. tuberculosis, XbaI restriction enzyme was applied for genome digestion. Finally, the digested DNA fragments were separated on 1% agarose gel and analyzed with GelCompar II software.

RESULTS

Genotyping of the studied isolates in comparison with the molecular weight marker revealed two common types; pulsotype A with 71 isolates and one multidrug resistant mycobacterium (MDR) case, and pulsotype B including 29 isolates and three MDR cases. No correlation between the antibiotypes and pulsotypes was observed.

CONCLUSIONS

Molecular epidemiology studies of infectious diseases have been useful when bacterial isolates have been clustered in a period of time and in different geographical regions with variable antibiotic resistance patterns. In spite of high geographical differences and different antibiotic resistant patterns, low genetic diversity among the studied TB isolates may refer to the low rate of mutations in XbaI restriction sites in the mycobacterial genome. We also identified three MDR isolates in low-incidence pulsotype B, which could be disseminated and is highly important to consider in TB surveillance programs to prevent the spread of MDR-TB isolates in the population.

Clinical Features and Epidemiology ofAcinetobacter baumanniiColonization and Infection in Spanish Hospitals

Objective:

To investigate the clinical features and the epidemiology ofAcinetobacter baumanniiin Spanish hospitals.

Design:

Prospective multicenter cohort study.

Setting:

Twenty-seven general hospitals and one paraplegic center in Spain.

Methods:

All cases ofA. baumanniicolonization or infection detected by clinical samples during November 2000 were included. Isolates were identified using phenotypic and genotypic methods. The molecular relatedness of the isolates was assessed by pulsed-field gel electrophoresis.

Results:

Twenty-five (89%) of the hospitals had 221 cases (pooled rate in general hospitals, 0.39 case per 1,000 patient-days; range, 0 to 1.17). The rate was highest in intensive care units (ICUs). Only 3 cases were pediatric. The mean age of the patients in the general hospitals was 63 years; 69% had a chronic underlying disease and 80% had previously received antimicrobial treatment. Fifty-three percent of the patients had an infection (respiratory tract, 51%; surgical site, 16%; and urinary tract, 11%). Crude mortality was higher in infected than in colonized patients (27% vs 10%; relative risk, 1.56; 95% confidence interval, 1.2 to 2.0;P= .003). Molecular analysis disclosed 79 different clones. In most hospitals, a predominant epidemic clone coexisted with other sporadic clones. Imipenem resistance was present in 39% of the hospitals.

Conclusions:

A. baumanniiwas present in most participating Spanish hospitals (particularly in ICUs) with different rates among them. The organisms mainly affected predisposed patients; half of them were only colonized. Epidemic and sporadic clones coexisted in many centers.

TypOn: the microbial typing ontology

Abstract

Bacterial identification and characterization at subspecies level is commonly known as Microbial Typing. Currently, these methodologies are fundamental tools in Clinical Microbiology and bacterial population genetics studies to track outbreaks and to study the dissemination and evolution of virulence or pathogenicity factors and antimicrobial resistance. Due to advances in DNA sequencing technology, these methods have evolved to become focused on sequence-based methodologies. The need to have a common understanding of the concepts described and the ability to share results within the community at a global level are increasingly important requisites for the continued development of portable and accurate sequence-based typing methods, especially with the recent introduction of Next Generation Sequencing (NGS) technologies. In this paper, we present an ontology designed for the sequence-based microbial typing field, capable of describing any of the sequence-based typing methodologies currently in use and being developed, including novel NGS based methods. This is a fundamental step to accurately describe, analyze, curate, and manage information for microbial typing based on sequence based typing methods.

Is biofilm formation related to the hypermutator phenotype in clinical Enterobacteriaceae isolates?

In bacteria, complex adaptive processes are involved during transition from the planktonic to the biofilm mode of growth, and mutator strains are more prone to producing biofilms. Enterobacteriaceae species were isolated from urinary tract infections (UTIs; 222 strains) and from bloodstream infections (BSIs; 213 strains). Relationship between the hypermutable phenotype and biofilm forming capacity was investigated in these clinical strains. Mutation frequencies were estimated by monitoring the capacity of each strain to generate mutations that conferred rifampicin resistance on supplemented medium. Initiation of biofilm formation was assayed by determining the ability of the cells to adhere to a 96-well polystyrene microtitre plate. UTI Enterobacteriaceae strains showed significantly higher biofilm-forming capacity: 63.1% (54.0% for E. coli strains) vs. 42.3% for BSI strains (47.7% for E. coli). Strains isolated from UTIs did not present higher mutation frequencies than those from BSIs: contrary to what has been widely described for P. aeruginosa strains, isolated from pulmonary samples in patients suffering from cystic fibrosis, no relationship was found between the hypermutator phenotype in Enterobacteriaceae and the ability to initiate a biofilm.

Effect of higher minimum inhibitory concentrations of quaternary ammonium compounds in clinical E. coli isolates on antibiotic susceptibilities and clinical outcomes

Quaternary ammonium compounds (QACs) are cationic surfactants used as preservatives and environmental disinfectants. Limited data are available regarding the effect of QACs in the clinical setting. We performed a prospective cohort study in 153 patients with Escherichia coli bacteraemia from February to September 2008 at University Hospital in Rennes. The minimum inhibitory concentrations (MICs) of antibiotics and QACs alkyldimethylbenzylammonium chloride (ADBAC) and didecyldimethylammonium chloride (DDAC) were determined by the agar dilution method. The capacity of biofilm production was assayed using the Crystal Violet method, and mutation frequencies by measuring the capacity of strains to generate resistance to rifampicin. Logistic regression analysis showed that one of the significant factors related to low MICs for ADBAC (≤16 mg/L) and DDAC (≤8 mg/L), was cotrimoxazole susceptibility (odds ratio: 3.72; 95% confidence interval: 1.22-11.24; P=0.02 and OR: 3.61; 95% CI: 1.56-7.56; P<0.01, respectively). Antibiotic susceptibility to cotrimoxazole was strongly associated with susceptibility to amoxicillin and nalidixic acid (P<0.01). Community-acquired or healthcare-associated bacteraemia, severity of bacteraemia, and patient outcome were independent of the MICs of ADBAC and DDAC. Our findings demonstrate an epidemiological relationship between higher MIC values of QACs in clinical E. coli isolates and antibiotic resistance.

Long-term control of hospital-wide, endemic multidrug-resistant Acinetobacter baumannii through a comprehensive "bundle" approach

BACKGROUND

Acinetobacter baumannii (Ab) is emerging as a multidrug-resistant (MDR) nosocomial pathogen of considerable clinical importance. Data on the efficacy of infection control measures in endemic situations are lacking. Here, we investigated the impact of a long-term multifaceted "bundle" approach in controlling endemic MDR Ab in a 950-bed tertiary care center.

METHODS

Ongoing staff education, promotion of hand hygiene, strict Contact and Isolation Precautions, environmental cleaning, and targeted active surveillance in high-risk areas during periods of likely transmission and contamination were initiated in this program. To assess the efficacy of our interventions, we recorded (before and after the intervention) the epidemiologic and clinical features of MDR Ab infections and determined the clonal relationship among MDR Ab bloodstream isolates by pulsed-field gel electrophoresis.

RESULTS

Before the "bundle" was instituted, the rate of colonization/infection was 0.82 cases per 100 admissions (1994-1995). Colonization/infection rates showed a sustained decrease after implementation of the control program in 1995 to 0.46 in 1996-1997 and to 0.21 in 1998-2003 (P < .001). Coincident with the institution of this program, the rate of bacteremia because of MDR Ab decreased 6-fold during the 8-year observation period. A notable change in the clonal distribution of the MDR Ab isolates was also demonstrated.

CONCLUSION

The implementation of a comprehensive and multifaceted infection control program ("bundle") in a tertiary care center effectively controlled the spread and clinical impact of MDR Ab.

Outbreak of Acinetobacter baumannii in a neonatal intensive care unit: antimicrobial susceptibility and genotyping analysis

PURPOSE

We describe an outbreak of nosocomial respiratory infection caused by multi-drug resistant Acinetobacter baumannii in a neonatal intensive care unit (NICU) in Tunis and our investigation to determine the source.

METHODS

Between May 2006 and February 2007, 31 infants hospitalized in the NICU of the Centre of Maternity and Neonatology of La Rabta in Tunis developed A. baumannii pneumonia. A case (infected infant) was defined as any patient hospitalized in the NICU during the outbreak period, with clinical signs of pneumonia and isolation of A. baumannii from tracheal aspirate. Ten rectal swabs and 98 environmental specimens were collected for the epidemiological investigation. Thirty-nine A. baumannii isolates were collected: 31 clinical strains from tracheal aspirates (>10(3) colony-forming units [CFU]/mL), 3 environmental strains from incubators, and 5 from rectal swab. For the genotyping method, we used pulsed-field gel electrophoresis using ApaI restriction endonuclease.

RESULTS

Thirty-one neonates developed multiple drug-resistant A. baumannii-associated pneumonia with 10 deaths due to A. baumannii infection, 48.4% had very low birth weight (<or=1500 g), and 67.7% neonates were premature. The mean age at the beginning of symptoms was 6.9 days. A. baumannii isolates were resistant to all beta-lactams. Resistance rates to other antibiotics were, respectively, 94.9% for gentamicin, 87.2% for cotrimoxazole, 41% for netilmicin, and 5.1% for tobramycin. All the isolates were susceptible to colistin. Pulsed-field gel electrophoresis analysis of outbreak-isolates indicated the presence of only one clone (A) containing nine subtypes genetically related to the outbreak strain.

CONCLUSION

The clonal diffusion of A. baumannii strains in an NICU was confirmed by molecular method. Control measures were reinforced to contain the outbreak.

Outbreak of Serratia marcescens in a neonatal intensive care unit: contaminated unmedicated liquid soap and risk factors

This study describes an outbreak of Serratia marcescens and its investigation and control in a neonatal intensive care unit (NICU). During a three-month period, five infants were colonised or infected by a single strain of S. marcescens. A case-control study, culture surveys and pulse-field gel electrophoresis analysis implicated a bottle soap dispenser as a reservoir of S. marcescens (P=0.032). Infants with S. marcescens colonisation or infection were also more likely to have been exposed to a central or percutaneous venous catheter (P=0.05) and had had longer exposure to endotracheal intubation (P=0.05). Soap dispensers are used in many hospitals and may be an unrecognised source of nosocomial infections. This potential source of infection could be reduced by using 'airless' dispensers which have no air intake for the distribution of soap. Prompt intervention and strict adherence to alcoholic hand disinfection were the key factors that led to the successful control of this outbreak.

Application of molecular techniques to the study of hospital infection

Nosocomial infections are an important source of morbidity and mortality in hospital settings, afflicting an estimated 2 million patients in United States each year. This number represents up to 5% of hospitalized patients and results in an estimated 88,000 deaths and 4.5 billion dollars in excess health care costs. Increasingly, hospital-acquired infections with multidrug-resistant pathogens represent a major problem in patients. Understanding pathogen relatedness is essential for determining the epidemiology of nosocomial infections and aiding in the design of rational pathogen control methods. The role of pathogen typing is to determine whether epidemiologically related isolates are also genetically related. To determine molecular relatedness of isolates for epidemiologic investigation, new technologies based on DNA, or molecular analysis, are methods of choice. These DNA-based molecular methodologies include pulsed-field gel electrophoresis (PFGE), PCR-based typing methods, and multilocus sequence analysis. Establishing clonality of pathogens can aid in the identification of the source (environmental or personnel) of organisms, distinguish infectious from noninfectious strains, and distinguish relapse from reinfection. The integration of molecular typing with conventional hospital epidemiologic surveillance has been proven to be cost-effective due to the associated reduction in the number of nosocomial infections. Cost-effectiveness is maximized through the collaboration of the laboratory, through epidemiologic typing, and the infection control department during epidemiologic investigations.

Subtracted restriction fingerprinting--a new typing technique using magnetic capture of tagged restriction fragments

Molecular typing of bacterial pathogens is an important issue in the epidemiological analysis of emerging infections in humans and animals. Numerous methods have been developed for and applied to a wide variety of bacteria of medical, veterinary and zoonotic importance. The present minireview provides a description of a new typing approach designated subtracted restriction fingerprinting (SRF), its use for typing of Salmonella isolates and a comparison with the most widely used typing techniques for these bacteria. SRF is based on double restriction endonuclease digestion of whole cell DNA, followed by a fill-in reaction with specifically tagged nucleotides and subtractive capture of selected restriction fragments. This results in a reduced number of fragments optimal for separation in standard agarose gels.

Risk factors for multidrug-resistant Pseudomonas aeruginosa nosocomial infection

A case-control study was conducted in a university hospital to determine the risk factors for nosocomial infection with multidrug-resistant Pseudomonas aeruginosa (MDR-PA) among all hospitalized patients and among those with a nosocomial infection due to P. aeruginosa. Eighty patients infected with MDR-PA, 75 infected with a non-MDR phenotype and 240 random controls were included in the 12-month study. Among all hospitalized patients, age, severity index, having a bedridden condition, transfer from other units, nasogastric feeding, urinary catheterization and exposure to beta-lactams (OR=2.5) or fluoroquinolones (OR=4.1) in the seven days before infection were linked to nosocomial infection due to MDR-PA. Among patients infected by P. aeruginosa, exposure to fluoroquinolones (OR=4.7) or surgery (OR=0.5) were linked to the isolation of MDR-PA. This study showed that, in addition to urinary catheterization, nasogastric feeding is an important risk factor in MDR-PA infection. Indeed, an imbalance in gut flora, modifications to the mucous membranes due to the use of nasogastric feeding and the selection pressures exerted by antibiotics were implicated in the occurrence of this infection.

Diversidad clonal y sensibilidad a los antimicrobianos de Acinetobacter baumannii aislados en hospitales españoles. Estudio multicéntrico nacional: proyecto GEIH-Ab 2000

INTRODUCTION

A nationwide multicenter study was performed in Spain to evaluate the clonal diversity and antimicrobial susceptibility of Acinetobacter baumannii clinical isolates.

METHODS

A total of 221 consecutive A. baumannii isolates recovered from clinical samples from 25 Spanish hospitals during November 2000 were studied. Isolate identification was performed by phenotyping methods and by amplified rDNA restriction analysis. Clonal relationships among A. baumannii isolates were determined by pulsed field gel electrophoresis. MICs of amikacin (AK), ampicillin (AP), cephalothin (CF), cefoxitin (FX), ceftazidime (CZ), ciprofloxacin (CP), cotrimoxazole (T/S), doxycycline (DX), gemifloxacin (GX), gentamicin (GN), imipenem (IP), meropenem (MP), minocycline (MI), piperacillin (PP), polymyxin B (PB), rifampicin (RI), tetracycline (TT), sulbactam (SB) and tobramycin (TO) were determined by microdilution (NCCLS guidelines).

RESULTS

Seventy-nine A. baumannii clones were differentiated. MIC50/MIC90 (mg/L) values for the 221 A. baumannii isolates were PP: > 512/> 512; AP, CF, FX: > 256/> 256; TT, GN: > 128/> 128; CZ: 128/> 256; CP: > 64/> 64; FP: 64/256; AK: 32/256; DX: 32/64; GX: > 16/> 16; TO: 16/128; SB, T/S: 16/64; MP: 8/> 128; IP: 4/128; RF: 4/8; MI: 2/16 and PB: 1/2. Percentages of susceptible isolates were PB: 100%; MI: 65.8%; IP: 52.5%, RF: 49.3%; SB: 46.7%; MP: 43.1%; AK: 34.7%; DX: 32.0%; TO: 21.3% and CZ, FP, GN, T/S, TT, GX, CP, AP, PP, CF and FX: < 20%.

CONCLUSIONS

A. baumannii isolates show high clonal variability in Spain. The most active antimicrobial agents against this organism were polymyxin B, minocycline, rifampicin, imipenem, sulbactam, meropenem, amikacin and doxycycline.

Molecular epidemiology of methicillin-resistant Staphylococcus aureus strains: state of affairs and tomorrow' s possibilities

Methicillin-resistant strains of Staphylococcus aureus (MRSA) have posed a clinical threat for nearly 40 years. During these years, an array of additional technologies suited for identification of MRSA below the species level has become available. The technologies, whether they assess phenotype or genotype, provide data that can be used for elucidation of the routes of dissemination of individual MRSA types. This review summarizes the current state of affairs with respect to the quality of the various laboratory techniques and includes descriptions of novel strategies such as binary typing and multilocus sequence typing (MLST). Drawbacks of procedures will be compared, and the value of molecular typing in the elucidation of complex biological phenomena, such as epidemicity, carriage, and reduced vancomycin susceptibility, will be indicated. Means for integrated assessment of bacterial biology, epidemiology, and population structure will be discussed.

Phenotypic and genotypic characterization of human and nonhuman Escherichia coli

Estuarine waters receive fecal pollution from a variety of sources, including humans and wildlife. Escherichia coli is one of several fecal coliform bacteria that inhabit the intestines of many warm-blooded animals that sometimes contaminate water. Its presence does not specifically implicate human fecal input, therefore it is necessary to differentiate contamination sources to accurately assess health risks. E. coli were isolated from human sources (HS) and nonhuman sources (NHS) in the Apalachicola National Estuarine Research Reserve and analyzed for fatty acid methyl ester (FAME), O-serogroup, and pulsed-field gel electrophoresis (PFGE) profiles. For FAME and PFGE analyses, there was no relationship between profile and isolate source. Human source PFGE profiles were less diverse than NHS isolates, and conversely for FAME. In contrast, O-serogrouping showed less diversity for HS vs. NHS isolates, and the predominant HS O-serogroups differed significantly (P < 0.01) from those of NHS isolates.

Beware of dogs licking ears

A patient with right-sided chronic purulent otorrhoea developed meningitis due to Pasteurella multocida transmitted by a dog that frequently licked his ear. We suggest that patients with a perforated tympanic membrane should avoid being licked on their ears by animals.

Discriminant analysis of ribotype profiles of Escherichia coli for differentiating human and nonhuman sources of fecal pollution

Estuarine waters receive fecal pollution from a variety of sources, including humans and wildlife. Escherichia coli is a ubiquitous bacterium in the intestines of warm-blooded animals and is used as an indicator of fecal pollution. However, its presence does not specifically differentiate sources of pollution. A total of 238 E. coli isolates from human sources (HS) and nonhuman sources (NHS) were collected from the Apalachicola National Estuarine Research Reserve, from associated sewage treatment plants, and directly from animals and tested for ribotype (RT) profile. HS and NHS isolates showed 41 and 61 RT profiles, respectively. At a similarity index of ca. 50%, HS and NHS isolates demonstrated four clusters, with the majority of HS and NHS isolates located in clusters C and D; isolates obtained directly from human and animal feces also could be grouped within these clusters. Discriminant analysis (DA) of RT profiles showed that 97% of the NHS isolates and 100% of the animal fecal isolates were correctly classified. The average rate of correct classification for HS and NHS isolates was 82%. We conclude that DA of RT profiles may be a useful method for identifying HS and NHS fecal pollution and may potentially facilitate management practices.

PCR detection of aminoglycoside resistance genes: a rapid molecular typing method for Acinetobacter baumannii

Aminoglycoside resistance is common among strains of Acinetobacter baumannii responsible for nosocomial infections, and inactivation of these antibiotics by enzymatic modification is the main mechanism. Different types of aminoglycoside acetyltransferases (AAC), nucleotidyltransferases (ANT), and phosphotransferases (APH) are synthesized by clinical isolates, and several enzymes can be produced by a single strain. Using a multiplex PCR procedure carried out on bacterial thermolysates, we analyzed the aminoglycoside resistance gene content of strains belonging to eight clusters identified by pulsed-field gel electrophoresis. In a single reaction were combined three primer pairs in order to amplify the genes coding for AAC(6')-Ih, AAC(3)-I, and AAC(3)-II, three primer pairs for the genes coding for ANT(2'')-I, APH(3')-VI, and rRNA 16S as internal control, and finally two primer pairs for the genes coding for AAC(6')-Ib and APH(3')-I. According to the aminoglycoside resistance gene patterns, the strains of the eight clusters were distributed into seven classes. This simple and rapid (< 8 h) fingerprinting technique could be a useful tool for the epidemiological investigation of A. baumannii nosocomial infections.

Unusual genetic heterogeneity of Acinetobacter baumannii isolates in a university hospital in Italy

BACKGROUND

Acinetobacter baumannii has become an increasingly important nosocomial pathogen, particularly in intensive care units (ICUs). The aim of this investigation was to study the molecular epidemiology of A baumanii in a university hospital in Italy.

METHODS

All A baumanii isolates were collected and typed with phenotypic and genotypic methods during a 7-month period. A 1-year prospective surveillance of ICU-acquired infections was performed by using the National Nosocomial Infections Surveillance methodology.

RESULTS

A baumanni accounted for 28.4% of all infections and 46.7% of all pneumonia acquired in the ICU, with a nosocomial infection rate of 12.4% or 8 infections per 1000 patient-days. Risk factors for A baumannii acquisition in the ICU were mechanical ventilation and previous use of broad-spectrum antibiotics, whereas administration of carbapenems showed a significant protective effect. Pulsed-field gel electrophoresis of genomic Apa I digests identified at least 5 outbreaks in the ICU caused by 5 different clones, one replacing the other in a well-defined temporal order.

CONCLUSIONS

Whereas the sequential temporal cluster of epidemic clones in the ICU is intriguing and requires further research, the clear evidence of cross-contamination of A baumannii isolates involved with infections in the ICU demands extensive preventive efforts.

Increasing incidence and comparison of nalidixic acid-resistant Salmonella enterica subsp. enterica serotype typhimurium isolates from humans and animals

We determined the resistance to quinolone of 309 Salmonella enterica subsp. enterica serotype Typhimurium strains isolated from humans and animals (cattle, pigs, or poultry) in 1995 or 1996. Nalidixic acid resistance increased from 8.5% in 1995 to 18.6% in 1996. The highest resistance levels correlated with a mutation at Ser-83 (or Asp-82). All strains remained ciprofloxacin susceptible. Human and animal isolates were compared by pulsed-field gel electrophoresis, and the banding patterns of the human isolates most closely matched those of the bovine isolates.

Nosocomial Candida glabrata colonization: an epidemiologic study

Candida glabrata has emerged as an important nosocomial pathogen, yet little is known about its epidemiology. We prospectively followed 98 patients admitted to a medical intensive care unit and the bone marrow transplant unit of a university hospital. Samples from environmental surfaces and the hands of hospital personnel were also cultured. Patients with newly acquired C. glabrata strains were compared to controls who were culture negative for C. glabrata. C. glabrata was recovered from multiple sites from 24 patients and three environmental surfaces. Sixteen patients (17%) acquired C. glabrata after admission to the study units. Significant risk factors for the nosocomial acquisition of C. glabrata were prolonged duration of hospitalization in the unit and prior antimicrobial use. Strain delineation by restriction enzyme analysis revealed 28 different strains of C. glabrata; three strain types were common to nine patients. The environmental isolates were of the same strain type and common to five patients (four patients with newly acquired strains). These results suggest the possibility of exogenous nosocomial acquisition of C. glabrata, including the possible acquisition from the hospital environment. Transmission may be by indirect contact since identical strains of C. glabrata were recovered from patients who were geographically and temporally associated.

Phenotypic and genotypic characterization of nosocomial Staphylococcus aureus isolates from trauma patients

Staphylococcus aureus is a major cause of nosocomial infections. During the period from March 1992 to March 1994, the patients admitted to the intensive care unit of the University of Maryland Shock Trauma Center were monitored for the development of S. aureus infections. Among the 776 patients eligible for the study, 60 (7.7%) patients developed 65 incidents of nosocomial S. aureus infections. Of the clinical isolates, 43.1% possessed a polysaccharide type 5 capsule, 44.6% possessed a type 8 capsule, and the remaining 12.3% had capsules that were not typed by the type 5 or type 8 antibodies. Six antibiogram types were noted among the infection-related isolates, with the majority of the types being resistant only to penicillin and ampicillin. It was noted that the majority of cases of pneumonia were caused by relatively susceptible strains, while resistant strains were isolated from patients with bacteremia and other infections. Only 16 (6.3%) of the isolates were found to be methicillin-resistant S. aureus (MRSA). DNA fingerprinting by pulsed-field gel electrophoresis showed 36 different patterns, with characteristic patterns being found for MRSA strains and the strains with different capsular types. Clonal relationships were established, and the origins of the infection-related isolates in each patient were determined. We conclude that (i) nosocomial infection-related isolates from the shock trauma patients did not belong to a single clone, although the predominance of a methicillin-resistant genotype was noted, (ii) most infection-related S. aureus isolates were relatively susceptible to antibiotics, but a MRSA strain was endemic, and (iii) for practical purposes, the combination of the results of capsular and antibiogram typing can be used as a useful epidemiological marker.

Epidemiological significance of cutaneous, pharyngeal, and digestive tract colonization by multiresistant Acinetobacter baumannii in ICU patients

The aim of this prospective study was to assess the relative epidemiological role of digestive tract colonization by Acinetobacter baumannii, in comparison with other body site colonizations, in patients admitted to intensive care units (ICUs). From January to May 1995, axillary, pharyngeal and rectal swabs were taken together within the first 48 h of admission, and then weekly during ICU stay. Seventy-three patients were included, 48 of them (66%) had axillary, pharyngeal, or rectal colonization with A. baumannii, nine (19%) of these 48 during the first 48 h and the remaining 28 (77%) during the first week. Twenty-one (29%) had clinical samples positive for A. baumannii and axillary, pharyngeal, or rectal colonization. In 15 of these 21 (71%), colonization on body sites occurred prior to isolation from clinical samples (mean seven days, range 1-20). Throughout admission, rates of detection of A. baumannii were 75% (36/48) for axillary or pharyngeal swabs and 77% (37/48) for rectal swabs. Combination of two body site swabs yielded culture positive rates of 90% (43/48) for axillary-pharyngeal or axillary-rectal sites, and 96% (46/48) for pharyngeal-rectal. Two epidemic clones were defined by antibiotype and pulsed-field gel electrophoresis (PFGE) of SmaI DNA digests in 48 isolates from 11 patients. We conclude that body sites of patients were a major reservoir for A. baumannii infections in the outbreak. This finding cases doubt on the value of selective decontamination of the digestive tract as an additional infection control measure in this kind of outbreak. The weekly performance of pharyngeal and rectal swabs appears to detect A. baumannii colonization early among ICU patients and enables barrier methods to be applied rapidly.

Utilization of both phenotypic and molecular analyses to investigate an outbreak of multidrug-resistant Salmonella anatum in horses

Phenotypic and molecular techniques, including antimicrobial susceptibility testing, plasmid analysis, and pulsed-field gel electrophoresis (PFGE) were used to characterize 15 isolates of multidrug-resistant (MDR) Salmonella anatum cultured during a 16 mo period from horses and a veterinary clinic environment. The isolates were resistant to multiple antimicrobial agents and could be placed into 4 groups based on their antimicrobial resistance patterns. The isolates contained multiple plasmids ranging in size from 2 to > 100 kb that could be grouped into 3 different plasmid profile patterns; these patterns did not correlate with the antimicrobial resistance groupings. Furthermore, antimicrobial resistance was conjugatively transferable. Digestion of genomic DNA from the 15 isolates with 3 different restriction endonucleases, SfiI, SpeI, and XbaI followed by PFGE revealed a highly conserved restriction endonuclease digestion pattern. In contrast, diverse banding patterns were observed with S. anatum obtained from other sources. These observations suggest that the MDR S. anatum isolates represent a common outbreak strain even though they possess different, albeit similar, antibiograms and plasmid profiles. The study showed that PFGE is a useful epidemiological tool for discriminating between unrelated and outbreak-related strains of S. anatum. In conclusion, epidemiological studies of outbreaks caused by MDR isolates of S. anatum should consist of both genotypic and phenotypic methods of analysis.

Investigation of a methicillin-resistant Staphylococcus aureus (MRSA) outbreak in an Irish hospital: triplex PCR and DNA amplification fingerprinting

Methicillin-resistant Staphylococcus aureus (MRSA) is becoming a problematic nosocomial pathogen. A continuing increase in numbers of isolates is reported from Irish hospitals each year. Preventing cross-infection and the further spread of endemic strains requires effective control measures. This necessitates the development of sensitive methods for both detection and genetic identification of MRSA isolates. In this study, 48 MRSA strains isolated in the Cork University Hospital were analysed between January and July 1995 using a one-tube triplex-polymerase chain reaction (PCR), wherein three genes, the methicillin-resistance gene (mecA), femA and the extracellular thermonuclease gene, nuc, were simultaneously amplified. Methicillin-sensitive S. aureus (MSSA) and coagulase-negative staphylococci (CNS) were also tested and the assay was found to be MRSA specific. The genetic relationship among this collection of MRSA isolates was also investigated. A single primer, RW3A, derived from a well-characterized, repetitive sequence found in Mycoplasma pneumoniae produced discriminating DNA fragment arrays with all the study organisms. The patterns were reproducible, even after several passages of the isolates. Quantitative analysis of the patterns divided the collection into two main groups, DAF group I representing 48% of the collection and DAF group II a further 19%. The remaining strains showed unrelated patterns. To fully outline the distribution of MRSA in this area a larger study will be necessary. This paper outlines the applicability of both the identification and fingerprinting techniques to local strains.

Multiresistant Pseudomonas aeruginosa serogroup O:11 outbreak in an intensive care unit

OBJECTIVE: To determine whether 15 multiresistant Pseudomonas aeruginosa isolates from an intensive care unit (ICU) outbreak were related, were endemic, and belonged to the O:12 European clone. METHODS: Forty-six P. aeruginosa isolates from a large hospital were investigated with respect to their antibiotic resistance profiles, serogroups, bacteriocin types and DNA fingerprints obtained by pulsed-field gel electrophoresis (PFGE) of genomic DNA digested with Xbal. RESULTS: Fourteen of the ICU outbreak isolates were indeed identical with respect to their serogroup, O:11, pyocin type, 10/a, and PFGE type, A. Clone A was endemic and dominant throughout the hospital, even though, within the ICU, it underwent phenotypic alterations, such as loss of cell wall lipopolysaccharide side-chains, or acquisition of ceftazidime and imipenem resistance. Bacteriocin typing was more discriminatory than serotyping, but PFGE could differentiate further among phenotypically identical strains. It also allowed the tracking of an O:6 strain, as it was becoming gradually more resistant and undergoing a bacteriocin-type conversion while remaining genotypically unaltered. CONCLUSIONS: Using three typing methods, a nosocomial multiresistant strain distinct from the previously described dominant European O:12 clone was characterized, and the ability of PFGE to identify clonal isolates even when these appear phenotypically distinct was demonstrated.

Macrorestriction analysis (PFGE) of serologically cross-reactive serovars of Acinetobacter baumannii and genospecies 3

Forty-two serovar reference strains of Acinetobacter baumannii and genospecies 3, which yielded major or minor, one-way or two-way (reciprocal) serological cross-reactions, were subjected to macrorestriction (SmaI, ApaI) analysis with the aid of pulsed-field gel electrophoresis (PFGE). The PFGE patterns of serovars 3 and 21 of genospecies 3 differed by 3 (SmaI) and 2-4 (ApaI) DNA fragments and thus were closely/possibly related in their genotype. Serovars 13 and 26 of genospecies 3 differed by only 2 DNA fragments (SmaI), suggesting close genetic relatedness; however, these two particular serovars of genospecies 3 appeared to be genotypically indistinguishable following restriction with ApaI. Serovars 2, 4, and 12 of genospecies 3 appeared to be unrelated to serovar 13 of genospecies 3 (SmaI); however, restriction with ApaI indicated a possible relatedness. Genospecies 3 serovars 2 and 26 differed by 5 DNA fragments (SmaI and ApaI), implying a possible relatedness. All other cross-reactive serovars examined proved to be genotypically unrelated, i.e., differed by > or = 7 DNA fragments (SmaI restriction).

Epidemiology of Staphylococcus aureus during space flight

Staphylococcus aureus was isolated over 2 years from Space Shuttle mission crewmembers to determine dissemination and retention of bacteria. Samples before and after each mission were from nasal, throat, urine, and feces and from air and surface sampling of the Space Shuttle. DNA fingerprinting of samples by digestion of DNA with SmaI restriction endonuclease followed by pulsed-field gel electrophoresis showed S. aureus from each crewmember had a unique fingerprint and usually only one strain was carried by an individual. There was only one instance of transfer between crewmembers. Strains from interior surfaces after flight matched those of crewmembers, suggesting microbial fingerprinting may have forensic application.

Comparison of Mycoplasma agalactiae isolates by pulsed field gel electrophoresis, SDS-PAGE and immunoblotting

We have analyzed 81 isolates of Mycoplasma agalactiae from four different regions of Italy between 1990 and 1995 in order to identify antigenic differences through SDS-PAGE and Western blotting and chromosomal DNA restriction endonuclease cleavage pattern differences. Antigenic variability in M. agalactiae isolates was investigated analyzing hydrophobic membrane protein fractions by immunoblotting using pooled sheep antiserum from naturally infected sheep. Large restriction fragments obtained cleaving genomic DNAs with SmaI, NruI, SalI, XhoI, BssHII and KpnI were analyzed by pulsed field gel electrophoresis. Genetic analysis indicates that isolates are all similar without intraspecific differences. This homogeneity was confirmed by immunoblotting: 80 and 50 kDa antigens are present in all strains analyzed.

DNA fingerprinting techniques for microorganisms. A proposal for classification and nomenclature

A whole array of DNA-fingerprinting techniques, which provide indirect access to DNA sequence polymorphism in order to assess species or clonal identity of bacterial organisms or in order to study bacterial genome composition, have been described during past decades. Nomenclature has been sometimes erroneous and/or confusing, also because of hybrid techniques that combine different approaches. It can be shown that most techniques study the sequence polymorphism of only the chromosome, or only the plasmid(s) or only a gene or gene fragment and that the sequence polymorphism is revealed by AFLP (amplified fragment length polymorphism) or by RFLP (restriction fragment length polymorphism) or by special electrophoresis techniques. Starting from these considerations, some taxonomy of techniques, which enables more appropriate nomenclature, can be developed.

Phenotypic and genotypic characterization of clinically recovered presumptive Acinetobacter baumannii isolates which failed to grow at 44 degrees C

Eleven clinical isolates of Acinetobacter, which exhibited an identical biochemical profile compatible with genospecies 3 and failed to grow at 44 degrees C, were not agglutinated by polyclonal rabbit immune sera against 26 serovars of genospecies 3. Rather, all 11 isolates reacted strongly with antiserum against serovar 18 of A. baumannii. Macrorestriction (SmaI) analysis of genomic DNA revealed that only one isolate was genotypically different, whereas the remaining ones were either closely related or identical. However, the genomic DNA of the A. baumannii serovar 18 reference strain proved to be genotypically unrelated.

Clusters of nosocomial cross-infection due to Acinetobacter baumannii and genospecies 3: comparison of serotyping with macrorestriction analysis of genomic DNA with pulsed-field gel electrophoresis

Triplets of isolates representing 20 putative clusters of nosocomial cross-infection due to Acinetobacter baumannii and genospecies 3 were examined comparatively using serotyping and analysis of restriction fragments (SmaI and ApaI) of genomic DNA with the aid of pulsed-field gel electrophoresis. Carbon source assimilation tests disclosed phenotypic variation among 6 to 20 triplets of isolates. Two misleading results of serotyping were encountered. With respect to the presumptive cluster No. 9, one of the genospecies 3 (originally serovar 4) isolates proved to be polyagglutinable upon repeat examination; this particular putative cluster was shown to be a pseudocluster by comparison of the macrorestriction profiles of the respective triple isolates. A strain of A. baumannii serovar 15 had infected 8 patients in a surgical intensive care unit, while a second, genotypically totally different strain of identical serovar had caused infection in one additional patient. With this exception, the correlation between serotyping and analysis of macrorestriction profiles was excellent.

Typing of nosocomial strains of Serratia marcescens: comparison of restriction enzyme cleaved genomic DNA fragment (PFGE) analysis with bacteriocin typing, biochemical profiles and serotyping

Eighty-eight selected clinical isolates of Serratia marcescens, representing 27 putative outbreaks of nosocomial cross-infection encountered during 1980-1995, were tested comparatively by bacteriocin typing, carbon source assimilation tests, serotyping (O and H antigens), and restriction pattern (RFLP) analysis of restriction cleaved (SpeI, XbaI) genomic DNA fragments after pulsed-field gel electrophoresis (PFGE). Serotyping served as the "gold standard" of the phenotypic methods. One pseudo-outbreak (bacteriocin typing incriminated type 26) was uncovered through serotyping as well as the biochemical profile and confirmed by PFGE analysis of genomic DNA. Bacteriocin typing and determination of biochemical profiles disclosed several instances of phenotypic variation; serotyping revealed two episodes of shifts from motility (H12) to nonmotility. Resolution of restricted genomic DNA fragments with the PFGE procedure permitted detection of 27 PFGE patterns (A-M, N-1-N-3, O-1, O-2, P-1-P-3, Q-1-Q-3, R-1-R-3, S-1, and T). Based on the analysis of PFGE patterns against the background of epidemiological data, the number of nosocomically significant strains of S. marcescens could be reduced to 16 (PFGE patterns A-M, N-2, O-1, P-2, and T). It was concluded that PFGE analysis of restricted genomic DNA of S. marcescens was superior to the three phenotypic methods.

Phenotypic variation of clinical Serratia marcescens isolates repeatedly recovered from individual patients

A total of 129 selected isolates of Serratia marcescens which had been recovered from 50 patients during the 1980-1995 period and which revealed phenotypic variation in terms of bacteriocin (phage tail) susceptibility, carbon source assimilation, or serotype, were reexamined with these three phenotypic methods. Seven isolates (5.4%) were bacteriocin nontypable; all 129 isolates utilized carbon sources and could be serotyped. Fourty-eight isolates from 20 patients yielded unambiguous results with these 3 phenotypic methods and were excluded from further analysis. Among the remaining 81 isolates from 30 patients, isolates from 2 patients revealed phenotypic variation in bacteriocin susceptibility only, whereas isolates from 6 patients showed variant bacteriocin types and variant biochemical profiles, but were of identical serotype. Isolates from 20 patients revealed variant biochemical profiles only. Three patients had become superinfected with strains of S. marcescens of different phenotype and genotype. In 4 patients, previously motile (H12) isolates had become nonmotile (H-). PFGE analysis of XbaI and SpeI-restricted genomic DNA of the 81 isolates of the 30 patients demonstrated the isolates of 22 patients to be genotypically identical. The isolates from 3 patients were closely related by genotype, and those from an additional patient proved to be possibly related. PFGE analysis demonstrated one patient to have become infected by two genotypically different strains of S. marcescens of identical serotype, which, however, differed in bacteriocin type and biochemical profile. It was concluded that PFGE analysis of restricted genomic S. marcescens DNA was superior to the three phenotypic methods examined comparatively. Serotyping was more reliable than bacteriocin typing, and the latter technique yielded fewer phenotypic variants than determination of biochemical profiles among consecutively recovered isolates from patients with long-lasting S. marcescens infection.

Polymorphism in Brucella strains detected by studying distribution of two short repetitive DNA elements

Thirty-four Brucella reference or field strains representing all the species and biovars were studied by repetitive element sequence-based PCR, a PCR using primers complementary to two enterobacterial short repetitive sequences: repetitive extragenic palindromic and enterobacterial repetitive intergenic consensus sequences. All the stains showed a positive amplification, suggesting that the Brucella genome contains such sequences. Repetitive extragenic palindromic PCR was less discriminating than enterobacterial repetitive intergenic consensus PCR in terms of distinguishing strains, but a combination of the two methods was able to distinguish all the isolates, except for some strains belonging to biovars 3 and 9 of Brucella abortus. Repetitive element sequence-based PCR appears to be a simple and useful method for the study of brucellosis epidemiology.

Molecular epidemiology of Klebsiella pneumoniae producing SHV-5 beta- lactamase: parallel outbreaks due to multiple plasmid transfer

Over a period of 22 months, 32 patients treated in three independent intensive care units of the Innsbruck University Hospital were infected with extended-spectrum beta-lactamase-producing members of the family Enterobacteriaceae (30 Klebsiella pneumoniae isolates, 1 Klebsiella oxytoca isolate, and 1 Escherichia coli isolate). As confirmed by sequencing of a bla gene PCR fragment, all isolates expressed the SHV-5-type beta-lactamase. Genomic fingerprinting of epidemic strains with XbaI and pulsed-field gel electrophoresis grouped 20 of 21 isolates from ward A into two consecutive clusters which included 1 of 3 ward B isolates. All six K. pneumoniae isolates from ward C formed a third cluster. Stool isolates of asymptomatic patients and environmental isolates belonged to these clusters as well. Additionally, 2,600 routine K. pneumoniae isolates from the surrounding provinces (population, 900,000) were screened for SHV-5 production. Only one of six nonepidemic isolates producing SHV-5 beta-lactamase was matched with the outbreak strains by genomic fingerprinting. Plasmid fingerprinting, however, revealed the epidemic spread of a predominant R-plasmid, with a size of approximately 80 kb, associated with 29 of the 30 K. pneumoniae isolates. This plasmid was also present in the single K. oxytoca and E. coli isolates from ward C and in three nonepidemic isolates producing SHV-5. Our results underline that strain typing exclusively on the genomic level can be misleading in the epidemiological investigation of plasmid-encoded extended-spectrum beta-lactamases. Our evidence for multiple events of R-plasmid transfer between species of the family Enterobacteriaceae in this nosocomial outbreak stresses the need for plasmid typing, especially because SHV-5 beta-lactamase seems to be regionally spread predominantly via plasmid transfer.

Genome macrorestriction analysis of sequential Pseudomonas aeruginosa isolates from bronchiectasis patients without cystic fibrosis

The respiratory tracts of bronchiectasis patients may be persistently colonized with Pseudomonas aeruginosa, despite intensive chemotherapy. The organism may undergo phenotypic changes in these patients, providing misleading typing results by conventional methods. We prospectively studied eight bronchiectasis patients without cystic fibrosis over a period of 1 year. A high microbial load of P. aeruginosa was found in 70% of sputum samples collected. Of these, 55 sequential P. aeruginosa isolates were characterized by a genotyping method, pulsed-field gel electrophoresis, to overcome the problem of differentiating the P. aeruginosa strains during chemotherapy. Genome macrorestriction fingerprinting patterns were analyzed after digestion with XbaI restriction endonuclease. Of the eight patients, six harbored a single dominant strain of P. aeruginosa, with an intrapatient macrorestriction similarity pattern range of 96 to 100%. The other two patients were infected with mixed bacterial isolates including P. aeruginosa. However, diversity was observed in the P. aeruginosa isolates from all eight patients, with a relatedness of only 55 to 65%. The study further strengthens the fact that pulsed-field gel electrophoresis can be used efficiently and effectively to differentiate P. aeruginosa strains in bronchiectasis patients without cystic fibrosis.

Discriminatory power and usefulness of pulsed-field gel electrophoresis in epidemiological studies of Pseudomonas aeruginosa

We assessed the discriminatory power of pulsed-field gel electrophoresis (PFGE) for the analysis of DNA restriction fragment length polymorphism (RFLP) in Pseudomonas aeruginosa. We determined DraI PFGE-RFLP of DNA of unrelated clinical and environmental strains, and clinical strains isolated from two intensive care units of the Besançon University Hospital. The typeability and reproducibility was 100%. The discriminatory index was 0.998, and the DNA patterns were stable in vitro and in vivo. There was a very low correlation between PFGE-RFLP and traditional typing methods. The typeability, reproducibility, the high discriminatory power and the stability of PFGE-RFLP make this a valuable method to be used in conjunction with serotyping. Further standardization and quantitative interpretation are possible and should lead to this technique becoming a library typing system.

Ribotyping to differentiate Fusobacterium necrophorum subsp. necrophorum and F. necrophorum subsp. funduliforme isolated from bovine ruminal contents and liver abscesses

Differences in biological activities (hemagglutination, hemolytic, leukotoxic, and virulence) and ribotypes between the two subspecies of Fusobacterium necrophorum of bovine ruminal and liver abscess origins were investigated. Hemagglutination activity was present in all hepatic, but only some ruminal, strains of Fusobacterium necrophorum subsp. necrophorum. Ruminal F. necrophorum subsp. necrophorum had low leukotoxin titers yet was virulent in mice. Fusobacterium necrophorum subsp. funduliforme of hepatic or ruminal origin had no hemagglutination activity, had low hemolytic and leukotoxic activities, and was less virulent to mice. For ribotyping, chromosomal DNAs of 10 F. necrophorum subsp. necrophorum and 11 F. necrophorum subsp. funduliforme isolates were digested with restriction endonucleases (EcoRI, EcoRV, SalI, PstI, and HaeIII) and examined by restriction fragment length polymorphisms after hybridizing with a digoxigenin-labeled cDNA probe transcribed from a mixture of 16 and 23S rRNAs from Escherichia coli. The most discriminating restriction endonuclease enzyme for ribotyping was EcoRI. The presence or absence of two distinct bands of 2.6 and 4.3 kb differentiated the two subspecies. Regardless of the origin, only F. necrophorum subsp. necrophorum, a virulent subspecies, had a ca. 2.6-kb band, whereas F. necrophorum subsp. funduliforme, a less virulent subspecies, had a ca. 4.3-kb band. Ribotyping appears to be a useful technique to genetically differentiate the two subspecies of F. necrophorum.

Comparative classification of Acinetobacter baumannii strains using seven different typing methods

A group of 49 Acinetobacter baumannii strains obtained from several hospital outbreaks and some sporadic cases were typed by biotyping, antimicrobial susceptibility testing, pulsed-field gel electrophoresis (PFGE), plasmid typing, multilocus enzyme electrophoresis, whole-cell protein profile, and Fourier-transform infrared (FT-IR) spectroscopy. All these methods have shown a high degree of reproducibility and are capable of recognising strains from the same epidemiological event. However, their power to discriminate between epidemiologically unrelated strains varies, with PFGE being superior to the other methods investigated. FT-IR spectroscopy, which has not yet been used for typing of Acinetobacter strains, proved to be a very rapid and highly reproducible method, but was somewhat limited in its discriminating power.

Genomic fingerprinting Acinetobacter baumannii: amplification of multiple inter-repetitive extragenic palindromic sequences

Acinetobacter species are important nosocomial pathogens. A rapid and sensitive identification system, capable of providing strain identity at the genetic level, is required to identify outbreak strains and facilitate the early implementation of infection control procedures. Repetitive extragenic palindromic (REP) elements, have been identified in numerous bacteria and these genomic sequences provide useful targets for DNA amplification. A method for amplifying inter-REP DNA sequences, REP-multiple arbitrary amplicon profiling (REP-MAAP), is described and applied to 29 Acinetobacter baumannii from clinical samples. Amplified polymorphic DNA patterns were demonstrated for all isolates and those displaying identical REP-MAAP patterns were considered identical at the genetic level. In the spring of 1993, 10 intensive care unit patients had endotracheal colonization with A. baumannii (five with REP-MAAP I and five with REP-MAAP II patterns). These findings suggested nosocomial transmission of organisms which was terminated by standard infection control measures. No further A. baumannii were detected until the winter of 1993 when isolates of different REP-MAAP groups emerged, suggesting that factors other than nosocomial transmission were implicated.