Tracking the Origin of Austrian Human Brucellosis Cases Using Whole Genome Sequencing

Brucellosis is a zoonotic disease caused by Brucella spp. and a major concern for livestock. Most human cases are caused by B. melitensis and clinical presentation is usually a mild febrile illness. However, treatment failure is frequent and more severe complications can occur. In Austria, every human brucellosis is investigated to determine whether it was imported from endemic areas or is the sign of an undetected autochthonous transmission. For this study, 21 B. melitensis strains isolated in Austria between 2005 and 2019 were collected, 17 strains from 15 different patients and four strains from cattle. Whole genome sequencing combined with core-genome MLST analysis was used to characterize these strains. A cluster of seven isolates from 2018 (three human and four cattle isolates) was identified, with fewer than two allelic differences. They corresponded to the only Austrian B. melitensis outbreak that happened over the past 15 years. The other 12 Austrian brucellosis cases were single cases, and geographical origins were available for 8/12. Genomic data was used to locate probable geographical origins and compared with the results of the epidemiological investigations. Austrian strains were compared with 67 published B. melitensis sequences available on NCBI. The result of genomic analysis matched for 7/8 cases with documented conclusion of the epidemiological investigation. Genome analysis also pointed to the geographical origin for three of the four cases with missing epidemiological data. Strains from six cases were grouped together (<40 allelic differences) with 4/6 cases imported from the Balkans. Additional B. melitensis isolates from Serbian animals were analyzed and grouped with this branch, suggesting frequent importation from Balkan countries to Austria. Overall, this study highlights the specificities of human brucellosis in Austria. It also underlines the value of whole genome sequencing as a tool to investigate brucellosis cases, allowing to identify and investigate outbreaks but also to support epidemiological investigation of imported cases. However, the reliability of such methods depends on the number of strains for comparison, which can be challenging in low incidence countries. Increasing the availability of published sequences with documented geographical origins would help establishing genomic-based methods for investigating brucellosis cases.

Oxazolidinone Resistance Mediated by optrA in Clinical Enterococcus faecalis Isolates in Upper Austria: First Report and Characterization by Whole Genome Sequencing

The genetic mechanisms associated with acquisition of linezolid (LZD) resistance are diverse, including point mutations in the V domain of the 23S rRNA and the 50S ribosomal proteins as well as cfr, optrA, and/or poxtA genes, which may be plasmid- or chromosomally encoded. The aim of this study was to investigate through Whole Genome Sequencing (WGS)-based typing the presence and location of genes and point mutations associated with LZD resistance in two Enterococcus faecalis isolates from Upper Austrian patients. The isolates were retrieved during screening by LZD disk diffusion test of a total of 911 clinical E. faecalis isolates in 2017. The two E. faecalis isolates had LZD minimum inhibitory concentrations of 8 and 32 mg/L and were optrA-positive (ST476 and ST585). Bioinformatic analysis revealed the presence of optrA located in the chromosome of both isolates. One isolate carried the optrA gene in the transposon 6674, previously reported as chromosomally encoded, and the second isolate in fragments originating from the integrative plasmid pEF10748. Additional mechanisms of LZD resistance on the 23S rRNA and the 50S ribosomal proteins were detected. None of the patients reported travels to geographical areas with high LZD resistance or previous LZD treatments. This is the first report of optrA carrying E. faecalis, including characterization by WGS from Austria. LZD resistance in a low-prevalence setting is of concern and should be further monitored.

Whole genome sequencing reveals resemblance between ESBL-producing and carbapenem resistant Klebsiella pneumoniae isolates from Austrian rivers and clinical isolates from hospitals

In 2016, the Austrian Agency for Health and Food Safety started a pilot project to investigate antimicrobial resistance in surface water. Here we report on the characterisation of carbapenem resistant and ESBL-producing K. pneumoniae isolates from Austrian river water samples compared to 95 clinical isolates recently obtained in Austrian hospitals. Ten water samples were taken from four main rivers, collected upstream and downstream of major cities in 2016. For subtyping and comparison, public core genome multi locus sequence typing (cgMLST) schemes were used. The presence of AMR genes, virulence genes and plasmids was extracted from whole genome sequence (WGS) data. In total three ESBL-producing strains and two carbapenem resistant strains were isolated. WGS based comparison of these five water isolates to 95 clinical isolates identified three clusters. Cluster 1 (ST11) and cluster 2 (ST985) consisted of doublets of carbapenem resistant strains (one water and one clinical isolate each). Cluster 3 (ST405) consisted of three ESBL-producing strains isolated from one water sample and two clinical specimens. The cities, in which patient isolates of cluster 2 and 3 were collected, were in concordance with the water sampling locations downstream from these cities. The genetic concordance between isolates from river water samples and patient isolates raises concerns regarding the release of wastewater treatment plant effluents into surface water. From a public health perspective these findings demand attention and strategies are required to minimize the spread of multiresistant strains to the environment.

Limited value of routine spa typing: a cross-sectional study of methicillin-resistant Staphylococcus aureus-positive patients in an Austrian hospital

BACKGROUND

We investigated whether spa typing is useful for indicating the setting of methicillin-resistant Staphylococcus aureus (MRSA) acquisition (community or health care acquired), the clinical relevance (colonization or infection), the type of infection (invasive or noninvasive), and the clinical outcome.

METHODS

Between August 2006 and December 2009, 381 routinely diagnosed culture-confirmed MRSA-positive patients were included into a cross-sectional study at an 800-bed hospital.

RESULTS

Out of 159 patients with colonization, 27 (17%) acquired MRSA in the community (CA-MRSA) and 123 (77.4%) in health care settings (HA-MRSA), and, of the 222 patients with infections, 119 (53.6%) had HA-MRSA and 103 (46.4%) had CA-MRSA. The 10 most frequent spa types accounted for 68.2% of the 346 typed MRSA isolates: t190 (28.3%), t032 (16.5%), t041 (9.4%), t008 (8.4%), t001 (3.4%), t002 (2.9%), t044 (3.1%), t223 (2.1%), t015 (2.1%), t127 (1.3%).

CONCLUSION

Spa typing of routinely identified MRSA isolates is unsuitable to predict the likeliness of an infection, of an invasive infection, and the clinical outcome. Molecular criteria such as spa type or Panton-Valentine leukocidin positivity used for classifying MRSA as either belonging to a community or hospital clone are of limited value to indicate the setting, where the MRSA strain was actually acquired according to epidemiologic criteria.

Detection of virulence-associated and regulatory protein genes in association with phage typing of human Vibrio cholerae from several geographical regions of the world

Vibrio cholerae O1, O139 and occasionally non-O1/non-O139 serogroups are most often responsible for epidemic and pandemic cholera. This study used genotypic patterns of PCR-based detection of virulence-associated and regulatory protein genes, along with phage typing, to characterize 86 V. cholerae strains. Thirty-eight of 53 O1 biotype El Tor strains harboured both tcpA classical and tcpA El Tor genes, and three El Tor strains lacked the V. cholerae O1-specific gene (Vc-O1); three O139 strains contained both Vc-O1 and Vc-O139 genes and seven out of ten non-O1/non-O139 strains possessed the Vc-O1 gene. The latter strains all harboured the virulence-associated genes ctxA, zot, ace, RS1, hlyA, ompU, rtxA and sxt. Two phage types, T27 and T25, were predominant in strains from different geographical regions of India, whereas more variation in phage susceptibility was observed for tetracycline-resistant strains from Kolkata. These results suggest that the pattern and distribution of virulence genes and phage types of V. cholerae are equally useful and discriminatory in tracing the origin of newly emerging strains.

Occurrence of Vibrio cholerae serogroups other than O1 and O139 in Austria

From 2000 to 2005, 13 infections due to non-O1/non-O139 Vibrio cholerae were documented in Austria. Twelve patients (8 years to 65 years old; 7 male) had symptomatic infections: diarrhea x 5, otitis x 6, septicemia once. All 5 patients who acquired their infections abroad, suffered from diarrhea. The 8 persons without travel history outside of Austria had otitis media (n = 4) or otitis externa (n = 2); the lethal case of septicemia affected a fisherman with underlying malignancy. One isolate was from an asymptomatic child. Detailed data on travel history inside Austria was available for 5 of these 8 patients: all 5 had visited or lived near Austria's largest lake. The concentration of salt in this westernmost steppe lake in Europe is approximately one-twentieth of that of sea water. Why otitis and not diarrhea is the dominating manifestation of non-O1/non-O139 infection acquired in Austria remains to be elucidated. We hypothesize that diarrhea due to Vibrio cholerae serogroups other than O1 and O139 acquired in Austria may simply be unrecognized by the standard operating procedures employed in clinical microbiology laboratories. Testing for Vibrio cholerae is not considered necessary for domestically acquired diarrhea. Only in patients who acquired diarrhea abroad, do physicians sometimes consider cholera as a differential diagnosis, thereby prompting the laboratory to use thiosulfate citrate bile salt sucrose (TCBS) agar plates.

The value of the World Wide Web for tele-education in radiology

We assessed Websites for radiological education. Of several hundred sites identified, 30 were randomly selected for evaluation by two groups of observers. All Web pages were rated with respect to time required to access the information; structure and organization of the site; image quality; and information content and relevancy. Rapid access was gained to many educational radiology Websites, which contained large numbers of interesting radiological images of good quality. A weak point was the structure and organization of the sites. The greatest variability in ratings was found in the information content and relevancy of the Websites.

Security aspects of teleradiology between the university centre and outlying hospitals in Tyrol

We assessed a data security system using biometric fingerprint techniques and smartcards to control access to a teleradiology system. Clinical cases were initially discussed between the referring physician and radiologist in Tyrol using a video-phone. Subsequent correspondence, including the transmission of images between the referring physician and the radiologist, was carried out by e-mail using the security system to prevent unauthorized access to patient information. Seventy-eight teleradiology sessions were conducted using this data security system. Speed and stability of data exchange were unaffected by the additional security feature. The average log-on time to the system was 7.8 s. The average training time on how to use the system was 15 min. The radiologist was able to issue a final patient report using the system within 1.5 of the initial contact. The data security feature was user-friendly and did not hinder the normal teleradiology consultation.

MRI findings in cerebral fat embolism

The purpose of this retrospective study was to demonstrate the MRI features of cerebral manifestations in patients with fat embolism syndromes in comparison with cerebral CT (CCT). Magnetic resonance imaging was performed according to standard protocols revealing multiple small non-confluent hyperintense intracerebral lesions larger than 2 mm on proton-density and T2-weighted images to various extents in three of four patients with clinically suspected cerebral fat embolism. Cerebral CT was negative in all patients. Our findings confirm that MRI can detect cerebral fat embolism with a higher sensitivity than CCT. Thus, MRI should be the first choice for imaging of cerebral fat embolism.

[Virtual endoscopy with post-processing helical CT data sets]

PURPOSE

The purpose of this work was to test a newly developed, post-processing software for virtual CT endoscopic methods. Virtual endoscopic images were generated from helical CT data sets in the region of the shoulder joint (n = 2), the tracheobronchial system (n = 3), the nasal sinuses (n = 2), the colon (n = 2), and the common carotid artery n = 1). Software developed specifically for virtual endoscopy ("Navigator") was used which, after a previous threshold value selection, makes the reconstruction of internal body surfaces possible by an automatic segmentation process. We have evaluated the usage of the software, the reconstruction time for individual images and sequences of images as well as the quality of the reconstruction. All pathological findings of the virtual endoscopy were confirmed by surgery.

RESULTS

The post-processing program is easy to use and provides virtual endoscopic images within 50 seconds. Depending of the extent of the data set, virtual tracheobronchoscopy as a cine loop sequence required about 15 minutes. Through use of the threshold value-dependent surface reconstruction the demands on the computer configuration are limited; however, this also created quality problems in image calculation as a consequence of the accompanying loss of data.

CONCLUSIONS

The Navigator software enables the calculation of virtual endoscopic models with only moderate demands on the hardware.

A cost analysis of an emergency computerized tomography teleradiology system

We carried out a cost analysis of a teleradiology system for emergency computerized tomography (CT) examinations. Teleradiology was implemented by connecting two spiral CT scanners in the University Hospital in Innsbruck and the Regional Hospital in Zwettl. It enabled the remote hospital in Zwettl to get fast and competent reports of emergency CT examinations when there was no specialist radiologist available. In 13 months' use for routine night and weekend service, the system proved fast and reliable. During the study period 121 emergency examinations of 116 patients were transmitted from Zwettl to Innsbruck. The fixed costs of teleradiology were for the ISDN connection and amounted to DM230 plus DM696/year rental. The average cost of one emergency CT examination by teleradiology was DM372 (range 308-453). One possible alternative, transporting the films by taxi for reporting elsewhere, was cheaper (estimated cost DM156), but would have been much slower. Another alternative, transporting the patient to the nearest central hospital for scanning, was much more expensive: DM524 by road or DM4667 by helicopter ambulance.

Technetium-99m human immunoglobulin scintigraphy in psoriatic arthropathy: first results

Standard bone scintigraphy [using technetium-99m methylene diphosphonate (MDP)] is widely held to be the most sensitive method for the early detection of psoriatic arthropathy. Preliminary results of this study reveal that 99mTc human immunoglobulin (HIG) scintigraphy demonstrates a typical premature pattern of extradermal psoriatic disease in digits indicative of the early stage of psoriatic arthritis. This pattern was also found in a rare case of psoriatic arthropathy without skin lesions. 99mTc-HIG scintigraphy appears to reveal the initial inflammatory characteristics of later bone lesions. In the advanced stage of psoriatic arthritis, 99mTc-MDP and 99mTc-HIG scans were found to be equally sensitive in the detection of the affected joints. Thus 99mTc-HIG scintigraphy seems to be useful in the early detection of psoriatic arthropathy and also in advanced psoriatic arthritis, as well as for the detection of psoriatic arthropathy without skin lesions.