The antibiotic resistance reservoir of the lung microbiome expands with age in a population of critically ill patients

Antimicrobial resistant lower respiratory tract infections are an increasing public health threat and an important cause of global mortality. The lung microbiome can influence susceptibility of respiratory tract infections and represents an important reservoir for exchange of antimicrobial resistance genes. Studies of the gut microbiome have found an association between age and increasing antimicrobial resistance gene burden, however, corollary studies in the lung microbiome remain absent. We performed an observational study of children and adults with acute respiratory failure admitted to the intensive care unit. From tracheal aspirate RNA sequencing data, we evaluated age-related differences in detectable antimicrobial resistance gene expression in the lung microbiome. Using a multivariable logistic regression model, we find that detection of antimicrobial resistance gene expression was significantly higher in adults compared with children after adjusting for demographic and clinical characteristics. This association remained significant after additionally adjusting for lung bacterial microbiome characteristics, and when modeling age as a continuous variable. The proportion of adults expressing beta-lactam, aminoglycoside, and tetracycline antimicrobial resistance genes was higher compared to children. Together, these findings shape our understanding of the lung resistome in critically ill patients across the lifespan, which may have implications for clinical management and global public health.

Viral Detection by Reverse Transcriptase Polymerase Chain Reaction in Upper Respiratory Tract and Metagenomic RNA Sequencing in Lower Respiratory Tract in Critically Ill Children With Suspected Lower Respiratory Tract Infection

OBJECTIVES

Viral lower respiratory tract infection (vLRTI) contributes to substantial morbidity and mortality in children. Diagnosis is typically confirmed by reverse transcriptase polymerase chain reaction (RT-PCR) of nasopharyngeal specimens in hospitalized patients; however, it is unknown whether nasopharyngeal detection accurately reflects presence of virus in the lower respiratory tract (LRT). This study evaluates agreement between viral detection from nasopharyngeal specimens by RT-PCR compared with metagenomic next-generation RNA sequencing (RNA-Seq) from tracheal aspirates (TAs).

DESIGN

This is an analysis of of a seven-center prospective cohort study.

SETTING

Seven PICUs within academic children's hospitals in the United States.

PATIENTS

Critically ill children (from 1 mo to 18 yr) who required mechanical ventilation via endotracheal tube for greater than or equal to 72 hours.

INTERVENTIONS

We evaluated agreement in viral detection between paired upper and LRT samples. Results of clinical nasopharyngeal RT-PCR were compared with TA RNA-Seq. Positive and negative predictive agreement and Cohen's Kappa were used to assess agreement.

MEASUREMENTS AND MAIN RESULTS

Of 295 subjects with paired testing available, 200 (68%) and 210 (71%) had positive viral testing by RT-PCR from nasopharyngeal and RNA-Seq from TA samples, respectively; 184 (62%) were positive by both nasopharyngeal RT-PCR and TA RNA-Seq for a virus, and 69 (23%) were negative by both methods. Nasopharyngeal RT-PCR detected the most abundant virus identified by RNA-Seq in 92.4% of subjects. Among the most frequent viruses detected, respiratory syncytial virus demonstrated the highest degree of concordance (κ = 0.89; 95% CI, 0.83-0.94), whereas rhinovirus/enterovirus demonstrated lower concordance (κ = 0.55; 95% CI, 0.44-0.66). Nasopharyngeal PCR was more likely to detect multiple viruses than TA RNA-Seq (54 [18.3%] vs 24 [8.1%], p ≤ 0.001).

CONCLUSIONS

Viral nucleic acid detection in the upper versus LRT reveals good overall agreement, but concordance depends on the virus. Further studies are indicated to determine the utility of LRT sampling or the use of RNA-Seq to determine LRTI etiology.

Outbreak of Invasive Group A Streptococcus in Children-Colorado, October 2022-April 2023

BACKGROUND

In the fall of 2022, we observed a sharp rise in pediatric Invasive Group A Streptococcus (iGAS) hospitalizations in Colorado. We compared the epidemiology, clinical features, and patient outcomes in this outbreak to prior years.

METHODS

Between October 2022 and April 2023, we prospectively identified and reviewed iGAS cases in hospitalized pediatric patients at Children's Hospital Colorado. Using laboratory specimen records, we also retrospectively compared the number of patients with sterile site GAS-positive cultures across three time periods: pre-COVID-19 (January 2015-March 2020), height of COVID-19 pandemic (April 2020-September 2022), and outbreak (October 2022-April 2023).

RESULTS

Among 96 prospectively identified iGAS cases, median age was 5.7 years old; 66% were male, 70% previously healthy, 39% required critical care, and four patients died. Almost 60% had associated respiratory viral symptoms, 10% had toxic shock syndrome, and 4% had necrotizing fasciitis. Leukopenia, bandemia, and higher C-reactive protein values were laboratory findings associated with need for critical care. There were significantly more cases during the outbreak (9.9/month outbreak vs 3.9/month pre-pandemic vs 1.3/month pandemic), including more cases with pneumonia (28% outbreak vs 15% pre-pandemic vs 0% pandemic) and multifocal disease (17% outbreak vs 3% pre-pandemic vs 0% pandemic), P < .001 for all.

CONCLUSIONS

Outbreak case numbers were almost triple the pre-pandemic baseline. The high percentage of cases with associated viral symptoms suggests a link to coinciding surges in respiratory viruses during this time. Invasive GAS can be severe and evolve rapidly; clinical and laboratory features may help in earlier identification of critically ill children.

The antibiotic resistance reservoir of the lung microbiome expands with age

Antimicrobial resistant lower respiratory tract infections (LRTI) are an increasing public health threat, and an important cause of global mortality. The lung microbiome influences LRTI susceptibility and represents an important reservoir for exchange of antimicrobial resistance genes (ARGs). Studies of the gut microbiome have found an association between age and increasing antimicrobial resistance gene (ARG) burden, however corollary studies in the lung microbiome remain absent, despite the respiratory tract representing one of the most clinically significant sites for drug resistant infections. We performed a prospective, multicenter observational study of 261 children and 88 adults with acute respiratory failure, ranging in age from 31 days to ≥ 89 years, admitted to intensive care units in the United States. We performed RNA sequencing on tracheal aspirates collected within 72 hours of intubation, and evaluated age-related differences in detectable ARG expression in the lung microbiome as a primary outcome. Secondary outcomes included number and classes of ARGs detected, proportion of patients with an ARG class, and composition of the lung microbiome. Multivariable logistic regression models (adults vs children) or continuous age (years) were adjusted for sex, race/ethnicity, LRTI status, and days from intubation to specimen collection. Detection of ARGs was significantly higher in adults compared with children after adjusting for sex, race/ethnicity, LRTI diagnosis, and days from intubation to specimen collection (adjusted odds ratio (aOR): 2.16, 95% confidence interval (CI): 1.10-4.22). A greater proportion of adults compared with children had beta-lactam ARGs (31% (CI: 21-41%) vs 13% (CI: 10-18%)), aminoglycoside ARGs (20% (CI: 13-30%) vs 2% (CI: 0.6-4%)), and tetracycline ARGs (14% (CI: 7-23%) vs 3% (CI: 1-5%)). Adults ≥70 years old had the highest proportion of these three ARG classes. The total bacterial abundance of the lung microbiome increased with age, and microbiome alpha diversity varied with age. Taxonomic composition of the lung microbiome, measured by Bray Curtis dissimilarity index, differed between adults and children (p = 0.003). The association between age and increased ARG detection remained significant after additionally including lung microbiome total bacterial abundance and alpha diversity in the multivariable logistic regression model (aOR: 2.38, (CI: 1.25-4.54)). Furthermore, this association remained robust when modeling age as a continuous variable (aOR: 1.02, (CI: 1.01-1.03) per year of age). Taken together, our results demonstrate that age is an independent risk factor for ARG detection in the lower respiratory tract microbiome. These data shape our understanding of the lung resistome in critically ill patients across the lifespan, which may have implications for clinical management and global public health.

Tobacco smoke exposure, the lower airways microbiome and outcomes of ventilated children

BACKGROUND

Tobacco smoke exposure increases the risk and severity of lower respiratory tract infections in children, yet the mechanisms remain unclear. We hypothesized that tobacco smoke exposure would modify the lower airway microbiome.

METHODS

Secondary analysis of a multicenter cohort of 362 children between ages 31 days and 18 years mechanically ventilated for >72 h. Tracheal aspirates from 298 patients, collected within 24 h of intubation, were evaluated via 16 S ribosomal RNA sequencing. Smoke exposure was determined by creatinine corrected urine cotinine levels ≥30 µg/g.

RESULTS

Patients had a median age of 16 (IQR 568) months. The most common admission diagnosis was lower respiratory tract infection (53%). Seventy-four (20%) patients were smoke exposed and exhibited decreased richness and Shannon diversity. Smoke exposed children had higher relative abundances of Serratia spp., Moraxella spp., Haemophilus spp., and Staphylococcus aureus. Differences were most notable in patients with bacterial and viral respiratory infections. There were no differences in development of acute respiratory distress syndrome, days of mechanical ventilation, ventilator free days at 28 days, length of stay, or mortality.

CONCLUSION

Among critically ill children requiring prolonged mechanical ventilation, tobacco smoke exposure is associated with decreased richness and Shannon diversity and change in microbial communities.

IMPACT

Tobacco smoke exposure is associated with changes in the lower airways microbiome but is not associated with clinical outcomes among critically ill pediatric patients requiring prolonged mechanical ventilation. This study is among the first to evaluate the impact of tobacco smoke exposure on the lower airway microbiome in children. This research helps elucidate the relationship between tobacco smoke exposure and the lower airway microbiome and may provide a possible mechanism by which tobacco smoke exposure increases the risk for poor outcomes in children.

Integrated host/microbe metagenomics enables accurate lower respiratory tract infection diagnosis in critically ill children

BACKGROUNDLower respiratory tract infection (LRTI) is a leading cause of death in children worldwide. LRTI diagnosis is challenging because noninfectious respiratory illnesses appear clinically similar and because existing microbiologic tests are often falsely negative or detect incidentally carried microbes, resulting in antimicrobial overuse and adverse outcomes. Lower airway metagenomics has the potential to detect host and microbial signatures of LRTI. Whether it can be applied at scale and in a pediatric population to enable improved diagnosis and treatment remains unclear.METHODSWe used tracheal aspirate RNA-Seq to profile host gene expression and respiratory microbiota in 261 children with acute respiratory failure. We developed a gene expression classifier for LRTI by training on patients with an established diagnosis of LRTI (n = 117) or of noninfectious respiratory failure (n = 50). We then developed a classifier that integrates the host LRTI probability, abundance of respiratory viruses, and dominance in the lung microbiome of bacteria/fungi considered pathogenic by a rules-based algorithm.RESULTSThe host classifier achieved a median AUC of 0.967 by cross-validation, driven by activation markers of T cells, alveolar macrophages, and the interferon response. The integrated classifier achieved a median AUC of 0.986 and increased the confidence of patient classifications. When applied to patients with an uncertain diagnosis (n = 94), the integrated classifier indicated LRTI in 52% of cases and nominated likely causal pathogens in 98% of those.CONCLUSIONLower airway metagenomics enables accurate LRTI diagnosis and pathogen identification in a heterogeneous cohort of critically ill children through integration of host, pathogen, and microbiome features.FUNDINGSupport for this study was provided by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Heart, Lung, and Blood Institute (UG1HD083171, 1R01HL124103, UG1HD049983, UG01HD049934, UG1HD083170, UG1HD050096, UG1HD63108, UG1HD083116, UG1HD083166, UG1HD049981, K23HL138461, and 5R01HL155418) as well as by the Chan Zuckerberg Biohub.

Investigating Health Disparities Associated With Multisystem Inflammatory Syndrome in Children After SARS-CoV-2 Infection

BACKGROUND

Multisystem inflammatory syndrome in children (MIS-C) is a postinfectious severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related complication that has disproportionately affected racial/ethnic minority children. We conducted a pilot study to investigate risk factors for MIS-C aiming to understand MIS-C disparities.

METHODS

This case-control study included MIS-C cases and SARS-CoV-2-positive outpatient controls less than 18 years old frequency-matched 4:1 to cases by age group and site. Patients hospitalized with MIS-C were admitted between March 16 and October 2, 2020, across 17 pediatric hospitals. We evaluated race, ethnicity, social vulnerability index (SVI), insurance status, weight-for-age and underlying medical conditions as risk factors using mixed effects multivariable logistic regression.

RESULTS

We compared 241 MIS-C cases with 817 outpatient SARS-CoV-2-positive at-risk controls. Cases and controls had similar sex, age and U.S. census region distribution. MIS-C patients were more frequently previously healthy, non-Hispanic Black, residing in higher SVI areas, and in the 95th percentile or higher for weight-for-age. In the multivariable analysis, the likelihood of MIS-C was higher among non-Hispanic Black children [adjusted odds ratio (aOR): 2.07; 95% CI: 1.23-3.48]. Additionally, SVI in the 2nd and 3rd tertiles (aOR: 1.88; 95% CI: 1.18-2.97 and aOR: 2.03; 95% CI: 1.19-3.47, respectively) were independent factors along with being previously healthy (aOR: 1.64; 95% CI: 1.18-2.28).

CONCLUSIONS

In this study, non-Hispanic Black children were more likely to develop MIS-C after adjustment for sociodemographic factors, underlying medical conditions, and weight-for-age. Investigation of the potential contribution of immunologic, environmental, and other factors is warranted.

IVIG Compared With IVIG Plus Infliximab in Multisystem Inflammatory Syndrome in Children

OBJECTIVES

To compare initial treatment with intravenous immunoglobulin (IVIG) versus IVIG plus infliximab in multisystem inflammatory syndrome in children (MIS-C).

METHODS

Single-center retrospective cohort study of patients with MIS-C who met Centers for Disease Control and Prevention criteria and received treatment from April 2020 to February 2021. Patients were included and compared on the basis of initial therapy of either IVIG alone or IVIG plus infliximab. The primary outcome was need for additional therapy 24 hours or more after treatment initiation.

RESULTS

Seventy-two children with MIS-C met inclusion criteria. Additional therapy was needed in 13 of 20 (65%) who received IVIG alone and 16 of 52 (31%) who received IVIG plus infliximab (P = .01). The median (interquartile range) ICU lengths of stay were 3.3 (2.2 to 3.8) and 1.8 (1.1 to 2.1) days, respectively (P = .001). New or worsened left ventricular dysfunction developed in 4 of 20 (20%) and 2 of 52 (4%) (P = .05), and new vasoactive medication requirement developed in 3 of 20 (15%) and 2 of 52 (4%), respectively (P = .13). The median percentage changes in the C-reactive protein level at 24 hours posttreatment compared with pretreatment were 0% (-29% to 66%) and -46% (-62% to -15%) (P < .001); and at 48 hours posttreatment, -5% (-41% to 57%) and -70% (-79% to -49%) respectively (P < .001). There was no significant difference in hospital length of stay, time to fever resolution, vasoactive medication duration, or need for diuretics.

CONCLUSIONS

Patients with MIS-C initially treated with IVIG plus infliximab compared with those treated with IVIG alone were less likely to require additional therapy and had decreased ICU length of stay, decreased development of left ventricular dysfunction, and more rapid decline in C-reactive protein levels.

Temporal airway microbiome changes related to ventilator-associated pneumonia in children

We sought to determine whether temporal changes in the lower airway microbiome are associated with ventilator-associated pneumonia (VAP) in children.Using a multicentre prospective study of children aged 31 days to 18 years requiring mechanical ventilation support for >72 h, daily tracheal aspirates were collected and analysed by sequencing of the 16S rRNA gene. VAP was assessed using 2008 Centers for Disease Control and Prevention paediatric criteria. The association between microbial factors and VAP was evaluated using joint longitudinal time-to-event modelling, matched case-control comparisons and unsupervised clustering.Out of 366 eligible subjects, 66 (15%) developed VAP at a median of 5 (interquartile range 3-5) days post intubation. At intubation, there was no difference in total bacterial load (TBL), but Shannon diversity and the relative abundance of Streptococcus, Lactobacillales and Prevotella were lower for VAP subjects versus non-VAP subjects. However, higher TBL on each sequential day was associated with a lower hazard (hazard ratio 0.39, 95% CI 0.23-0.64) for developing VAP, but sequential values of diversity were not associated with VAP. Similar findings were observed from the matched analysis and unsupervised clustering. The most common dominant VAP pathogens included Prevotella species (19%), Pseudomonas aeruginosa (14%) and Streptococcus mitis/pneumoniae (10%). Mycoplasma and Ureaplasma were also identified as dominant organisms in several subjects.In mechanically ventilated children, changes over time in microbial factors were marginally associated with VAP risk, although these changes were not suitable for predicting VAP in individual patients. These findings suggest that focusing exclusively on pathogen burden may not adequately inform VAP diagnosis.

Multisystem Inflammatory Syndrome in Children: Survey of Protocols for Early Hospital Evaluation and Management

OBJECTIVE

To describe the similarities and differences in the evaluation and treatment of multisystem inflammatory syndrome in children (MIS-C) at hospitals in the US.

STUDY DESIGN

We conducted a cross-sectional survey from June 16 to July 16, 2020, of US children's hospitals regarding protocols for management of patients with MIS-C. Elements included characteristics of the hospital, clinical definition of MIS-C, evaluation, treatment, and follow-up. We summarized key findings and compared results from centers in which >5 patients had been treated vs those in which ≤5 patients had been treated.

RESULTS

In all, 40 centers of varying size and experience with MIS-C participated in this protocol survey. Overall, 21 of 40 centers required only 1 day of fever for MIS-C to be considered. In the evaluation of patients, there was often a tiered approach. Intravenous immunoglobulin was the most widely recommended medication to treat MIS-C (98% of centers). Corticosteroids were listed in 93% of protocols primarily for moderate or severe cases. Aspirin was commonly recommended for mild cases, whereas heparin or low molecular weight heparin were to be used primarily in severe cases. In severe cases, anakinra and vasopressors frequently were recommended; 39 of 40 centers recommended follow-up with cardiology. There were similar findings between centers in which >5 patients vs ≤5 patients had been managed. Supplemental materials containing hospital protocols are provided.

CONCLUSIONS

There are many similarities yet key differences between hospital protocols for MIS-C. These findings can help healthcare providers learn from others regarding options for managing MIS-C.

408. Evaluation of the negative predictive value of the SARS-CoV-2 PCR respiratory assays in asymptomatic children undergoing surgery

Background

Universal pre-operative screening with SARS-CoV-2 PCR has been adopted by institutions to mitigate risk to healthcare workers (HCW) during aerosol-generating procedures such as intubation. However, there remains uncertainty regarding rates of false negative results and optimal sampling type. The objective was to determine the reliability of single, pre-operative SARS-CoV-2 testing from the nasopharynx in children undergoing general anesthesia.

Methods

Children < 18 years of age who underwent intubation for a procedure received pre-operative testing 24–48 hours prior with a nasopharyngeal (NP) swab or wash, in conjunction with intra-operative nasal wash (NW) and tracheal aspirate (TA) sampling. All paired samples underwent testing using the Simplexa DiaSorin platform or a modified Centers for Disease Control assay. Cohen’s Kappa was used for interrater reliability of each sample result. McNemar’s Test was used to compare result proportions by sample type. Positive and negative predictive values (PPV, NPV) were calculated based on the intraoperative NW as the reference standard. Analyses were conducted using SAS (v 9.4).

Results

We collected full sample sets from 364 children from April 14 to May 15; 66% of pre-operative samples were NP swabs. The median age was 6 years (IQR 2,13), 55% were male, 68% were white and 41% of children had a high-risk comorbidity. Most surgeries were conducted by general surgery (23%), followed by orthopedics (19%). Only 2.5% of children had respiratory symptoms, and 4.8% had a documented fever within a week of the procedure. SARS-CoV-2 positive samples occurred in 4/364 (1%) of pre-operative samples, 8/363 (2.2%) of intra-operative samples, and 8/348 (2.3%) of TA samples. The pre-operative test had 100% PPV and 99% NPV, and the TA had 100% PPV and 98.6% NPV (Table 1). There was very good agreement (Figure) between pre- and intraoperative upper respiratory sampling, with a Kappa of 0.66, (95% CI 0.35–0.97). There was no statistical difference in results by sample type.

Table 1. Comparison of intra-operative and pre-operative nasopharyngeal sample results, test characteristics and test concordance

Table 2. Comparison of intra-operative nasopharyngeal and tracheal aspirate sample results, test characteristics and test concordance

Figure 1 Percent agreement between pre-operative and intra-operative samples

Conclusion

There is a high PPV and NPV of pre-operative SARS-CoV-2 PCR testing among children undergoing anesthesia. These data can help inform guidelines regarding appropriate precautions for HCW performing high risk procedures in asymptomatic pediatric patients.

Disclosures

Suchitra Rao, MD, BioFire (Grant/Research Support) Samuel Dominguez, MD, PhD, BioFire (Consultant, Research Grant or Support)

Ending student mistreatment: early successes and continuing challenges

Problem: Student mistreatment represents an ongoing challenge for US medical schools. Students experiencing mistreatment may become marginalized and cynical, and they have higher rates of burnout, depression and substance use disorders. Although numerous attempts to eliminate mistreatment have been proposed, best practices remain elusive. We formed a unique student-faculty collaboration (the Ending Mistreatment Task Force) that allowed all voices to be heard and enabled identification of five interventions to reduce mistreatment.Intervention: The EMTF developed and implemented five key interventions: 1) a shared mistreatment definition; 2) measures to increase faculty accountability, including adding professionalism expectations to faculty members' contracts and performance reviews; 3) a Professionalism Office to respond promptly to students' reports of mistreatment and provide feedback to faculty; 4) tools to help teachers provide authentic learning environments for students, while addressing generational misunderstandings; and 5) student-produced videos, helping faculty understand the impact of mistreatment as seen through students' eyes.Context: These interventions occurred at one medical school where mistreatment reports were consistently above national averages.Impact: Over 6 years, the interventions helped reduce the rate of student-reported mistreatment by 36% compared with a 4% decline across all US medical schools.Lessons: The collaborations between students and faculty helped each party identify unexpected misunderstandings and challenges. We learned that students want hard questions, although faculty are often afraid to challenge students for fear of offending them or being reported. We clarified differences between mistreatment and sub-optimal learning environments and openly discussed the pervasive opinion that 'some' mistreatment is important for learning. We also identified ongoing challenges, including the need to solicit residents' perspectives regarding mistreatment and develop proper responses to disrespectful comments directed at patients, family and colleagues. The collaboration reinforced students' and faculty members' shared commitment to upholding a respectful learning and clinical care environment and ending mistreatment.

Viral gastroenteritis in children in Colorado 2006-2009

Acute gastroenteritis accounts for a significant burden of medically attended illness in children under the age of five. For this study, four multiplex reverse transcription PCR assays were used to determine the incidence of adenovirus, astrovirus, coronavirus, norovirus GI and GII, rotavirus, and sapovirus in stool samples submitted for viral electron microscopy (EM) to the Children's Hospital Colorado. Of 1105 stool samples available, viral RNA/DNA was detected in 247 (26.2%) of 941 pediatric samples (median age = 2.97 years, 54% male) with 28 (3.0%) positive for more than one virus. Adenovirus, astrovirus, norovirus GI, norovirus GII, rotavirus, and sapovirus were detected in 95 (10.0%), 33 (3.5%), 8 (0.9%), 90 (9.6%), 49 (5.2%), and 2 (0.2%) of the pediatric samples, respectively. No coronaviruses were identified. Sequencing of norovirus positive samples indicated an outbreak of norovirus strain GII.4 in 2006 with evidence of numerous circulating strains. Multiple samples from the same immunocompromised patients demonstrated symptomatic shedding of norovirus for up to 32 weeks and astrovirus for 12 weeks. RT‐PCR detected 99 of 111 (89%) adenovirus‐positive samples versus 12 (11%) by EM, and 186 of 192 (97%) sapovirus/astrovirus/norovirus‐positive samples versus 21 (11%) by EM. Noroviruses and adenoviruses are common causes of gastroenteritis in children. Immunocompromised patients can be infected with multiple viruses and shed viruses in their stools for prolonged periods. This data support the superiority of RT‐PCR compared to EM for diagnosis of viral gastroenteritis. J. Med. Virol. 87:931–939, 2015. © 2015 Wiley Periodicals, Inc.

Development of a technique to quantify the effectiveness of enrichment regimes in recovering "stressed" Listeria cells

A rapid, reliable microwell plate method based on the most probable number (MPN) technique was used to determine the effectiveness of five enrichment regimes in the recovery and enumeration of Listeria spp. cells from five seafood products. The products tested were chosen to reflect conditions under which cells were exposed to the "stresses" associated with a variety of food-processing techniques, such as treatments involving an ethanol-based marinade, lowered pH (acetic acid), heat, sugar and salt brine (Gravilax), or frozen storage. Either Listeria monocytogenes and Listeria innocua were present in food samples as natural contaminants or L monocytogenes was added in the laboratory. Listeria repair broth (LRB), buffered Listeria enrichment broth, Listeria enrichment broth (LEB), Fraser broth, and University of Vermont modified Listeria enrichment broth were used to recover Listeria cells. The effectiveness of these enrichment regimes was found to be dependent on the type of stresses the cells had been exposed to. After exposure to ethanol, recovery of L monocytogenes cells was inhibited in enrichment regimes involving a nonselective period of resuscitation. On exposure to acetic acid, there were no significant differences (P < 0.05) between any of the regimes used. With heat-stressed cells, LRB recovered significantly fewer (P < 0.05) cells than did any other medium. On exposure to osmotic stress (elevated sugar and salt concentrations), LEB recovered the fewest cells. The largest number of cells was recovered from frozen fish (Hoki [Macruronus novazelandiae]) fillets with LRB. No single enrichment regime was consistently the most effective.

Survival of Listeria monocytogenes attached to stainless steel surfaces in the presence or absence of Flavobacterium spp

Contaminated surfaces of food processing equipment are believed to be a significant source of Listeria monocytogenes to foods. However, very little is known about the survival of Listeria in processing environments. In a mixed bacterial biofilm of L. monocytogenes and Flavobacterium spp., the number of L. monocytogenes cells attaching to stainless steel increased significantly compared to when L. monocytogenes was in a pure culture. The L. monocytogenes cells in the mixed biofilms were also recoverable for significantly longer exposure periods. On colonized coupons held at 15 degrees C and 75% humidity, decimal reduction times were 1.2 and 18.7 days for L. monocytogenes in pure and mixed biofilms, respectively. With increasing exposure time, the proportion of cells that were sublethally injured (defined as an inability to grow on selective agar) increased from 8.1% of the recoverable cell population at day 0 to 91.4% after 40 days' exposure. At 4 and -20 degrees C, decimal reduction times for L. monocytogenes in pure culture were 2.8 and 1.4 days, respectively, and in mixed culture, 10.5 and 14.4 days, respectively. The enhanced colonization and survival of L. monocytogenes on "unclean" surfaces increase the persistence of this pathogen in food processing environments, while the increase in the percentage of sublethally injured cells in the population with time may decrease the ability of enrichment regimes to detect it.

Application of the Bigelow (z-value) model and histamine detection to determine the time and temperature required to eliminate Morganella morganii from seafood

In New Zealand, the product most frequently implicated in cases of scombroid or histamine poisoning is the hot-smoked fish, kahawai (Arripis trutta). A properly controlled heating step in the production of hot-smoked seafood could eliminate bacteria able to convert the amino acid histidine to histamine. In this study, we determined the core temperatures and times required during hot smoking of kahawai to eliminate histamine-forming bacteria and to ensure a final product that will not produce histamine if subsequent temperature abuse occurs. Morganella morganii strains previously isolated from portions of hot-smoked kahawai with elevated histamine levels were inoculated onto product to be tested. A variation of the Bigelow or z-value model was used to generate a thermal death time graph, where the production of histamine, in a heat-treated and subsequently temperature-abused sample, was scored as a positive value (growth) and the absence of histamine was scored as a negative value (no growth). From a line fitted to the data, calculated times for the elimination of histamine-forming bacteria at test temperatures of 58, 59, 60, 61, and 62 degrees C were estimated to be 15.27, 8.81, 4.79, 2.68, and 1.46 min, respectively, giving a z value of 3.85 degrees C. This approach to thermal death determination, based on the presence or absence of a bacterial metabolite, proved to be an efficient way to determine the thermal regime required to eliminate bacteria capable of converting histidine to histamine on kahawai.

Survival of Listeria monocytogenes in sea water and effect of exposure on thermal resistance

Survival, recoverability and sublethal injury of two strains of Listeria monocytogenes, Scott A and an environmental strain KM, on exposure to sea water at 12.8 or 20.8 degrees C was determined using in situ diffusion chambers. Plate counts were used to assess recoverability and injury while 5-cyano-2,3-ditolyl tetrazolium chloride (CTC) reduction was used to determine respiratory activity. T90 values (times for 10-fold decreases in numbers of recoverable cells) on non-selective medium (trypticase soya agar with 0.6% yeast extract) at 12.8 and 20.8 degrees C were 61.7 and 69.2 h for L. monocytogenes Scott A, and 103.0 and 67.0 h for L. monocytogenes KM, respectively. On selective medium (Oxford agar), T90 values at 12.8 and 20.8 degrees C were 60.6 and 56.9 h for L. monocytogenes Scott A, and 83.0 and 65.9 h for L. monocytogenes KM, respectively. With Scott A, the percentage of sublethally injured cells at 12.8 and 20.8 degrees C was 1.7 and 17.7%, respectively, while for KM the values were 19.0 and 1.6%, respectively. The fraction of cells reducing CTC but which were not recoverable on plating progressively increased on exposure to sea water. Listeria monocytogenes KM challenged at 58 degrees C showed an apparent increase in heat resistance after exposure to sea water at 20.8 degrees C for 7 d (D58 = 2.64 min) compared with before exposure (D58 = 1.24). This increase in thermal resistance was not apparent at temperatures greater than 63 degrees C, and analysis of the best-fit regression lines fitted to the thermal data obtained from the two cell populations indicated that their thermal resistance was not significantly different (P > 0.05) over the temperature range tested (58-62 degrees C).

Thermal death times of Hafnia alvei cells in a model suspension and in artificially contaminated hot-smoked kahawai (Arripis trutta)

In New Zealand the product most frequently implicated in cases of scombroid poisoning is hot-smoked kahawai (Arripis trutta). Using a Hafnia alvei strain, previously isolated from a portion of hot-smoked kahawai with a histamine level of 1,659.4 mg/kg, thermal death trials were carried out in a model suspension (0.1% peptone) at 54, 55, 56, 57, and 58 degrees C. From the linear regression line (R2 = 0.98) fitted to observed D values plotted against temperature, calculated D values for 54, 55, 56, 57, and 58 degrees C were estimated to be 0.63, 0.36, 0.20, 0.11, and 0.06 min, respectively, giving a z value of 4.14 degrees C. Thermal death trials were also carried out for H. alvei associated with hot-smoked kahawai at 54, 55, 55.5, 56, and 57 degrees C. From the linear regression line (R2 = 0.93) fitted to the data, calculated D values for 54, 55, 56, and 57 degrees C were estimated to be 1.42, 0.74, 0.38, and 0.20 min, respectively, giving a z value of 3.57 degrees C. Results indicate that hot smoking has the potential to eliminate H. alvei from seafood products.

Reducing total aerobic counts and Listeria monocytogenes on the surface of king salmon (Oncorhynchus tshawytscha)

A trial industrial-scale fin-fish washing system was assessed for its effectiveness in removing bacteria associated with the skin of gilled and gutted king salmon (Oncorhynchus tshawytscha). Exposure of the salmon to 200 ppm free chlorine at a turnover rate for the total volume of the wash solution of 2.25 cycles h-1 for 120 min resulted in decreases in the aerobic plate count (APC) recovered from the salmon ranging from 96.6 to 99.2%. In order to optimize the washing regime a laboratory-scale fin-fish washing system was developed. Twenty-six washing treatments were used to generate a model to relate efficacy of bacterial removal with chlorine concentration, flow rate, and duration of washing. The model gave two local maxima of percentage APC reduction, one of 99.3% at a concentration of 126.3 ppm chlorine with a turnover of 0.75 cycle h-1 and a duration of 71.3 min and a second of 100.6% at a concentration of 126.3 ppm chlorine with a turnover of 3.75 cycles h-1 and a duration of 120 min. In additional experiments, it was determined that washing could eliminate 99.79% of Listeria monocytogenes cells that had been artificially inoculated onto the surface of gilled and gutted salmon. It was concluded that while chlorinated wash regimens have the potential to reduce the carriage of bacteria, including L. monocytogenes, into fish-processing facilities, they will not ensure an L. monocytogenes-free product. Further, the use of such a system has to be assessed with regard to allowable chlorine levels (subject to regulation), the effect of washing on the quality of the finished product, and the cost of water purchase and disposal.

HIV/AIDS in resource-poor settings: comprehensive care across a continuum

BACKGROUND

The scale of the HIV pandemic in many resource-poor settings (RPS) has overwhelmed the already impoverished health and social support systems.

OBJECTIVE

To propose a feasible and applicable model of care which can be used at district level in RPS faced with the prospect of caring for increasing numbers of persons living with HIV and AIDS (PWA) requiring care, and to outline some of the immediate challenges and directions for research.

METHODS

Using Zambia as a test case, a review of existing community and health institution-based care programmes and facilities was made, and opportunities missed in meeting the demands of PWA were identified.

RESULTS

Many opportunities have been missed both in encouraging PWA to enter the care continuum and in strengthening existing care services. An affordable and accessible model of care at district level that is not dependent on expensive drugs or medical interventions is suggested, using Zambia as an example. The model requires changes in the structure, function and HIV/AIDS care messages that are in line with new knowledge about the disease.

CONCLUSION

This model of cooperation and sharing between health and social public/private and voluntary systems can be developed over time at a district level within existing resources, even as the pattern of the epidemic alters and resources become more available and better managed.

Efficacy of marinades against Listeria monocytogenes cells in suspension or associated with green shell mussels (Perna canaliculus)

In order to determine the listericidal efficacies of three marinades used in the production of marinated green shell mussels (Perna canaliculus), decimal reduction times (D values) were determined for a mixture of seven strains of Listeria monocytogenes exposed to marinades in the presence and absence of mussels. With an acetic acid (1.5%, wt/vol) marinade, calculated D values in the presence and absence of mussels were 77.3 and 33.3 h, respectively. Likewise, for an acetic acid (0.75%)-lactic acid (0.75%) marinade and an acetic acid (1.5%)-Glucono Delta-Lactone (0.2%)-based marinade, the D values in the presence and absence of mussels were 125.5 and 26.9 h and 86.3 and 19.3 h, respectively. Various increases in decimal reduction times in the presence of mussels indicated that there was no simple relationship between the listericidal natures of these marinades and the presence of mussels. This result suggests that difficulties may occur in trying to relate acid inhibition studies carried out in model broth systems to "real food" systems.

Infiltrative clival pituitary adenoma of ectopic origin

An ectopic pituitary adenoma is a rare entity that may occur in several anatomic locations, the sphenoid sinus being the most common. Many of these tumors are amenable to surgical resection by means of a transsphenoidal approach. A more aggressive surgical approach is needed to attempt resection of extensive tumors that involve the clivus and the nasopharynx. Complete resection in these areas cannot always be guaranteed or determined, necessitating postoperative radiotherapy. Many different tumors of the sphenoid sinus and skull base can resemble ectopic pituitary adenomas on radiologic assessments. Because of this, preoperative endocrine assessment is recommended.

Scalp hair patterns in mental subnormality

Scalp hair patterns have been examined in 1901 healthy subjects and 1789 severely subnormal patients. Patients with Down's syndrome had a highly significant excess of midline occipital whorls and a deficit of right-sided occipital whorls. Five out of 44 patients with microcephaly had a distinct 'up-sweep' of the frontal hair, a much lower proportion than found previously. Patients with unspecified mental subnormality had a highly significant deficit of multiple occipital whorls. Cutis verticis gyrata was noted incidentally in 15 subnormal patients, 13 of whom were males. Observation of hair patterns in individual patients with mental subnormality is of theoretical interest but is unlikely to be of great practical value.