Sea water whirlpool spa as a source of Legionella infection

Bacterial pneumonia caused by the inhalation of aerosols contaminated with Legionella spp. is also known as Legionnaires' disease. In this study, we report a case of pneumonia caused by Legionella pneumophila sg.1 in a 58-year-old man who visited a sea water-filled whirlpool within a hotel and spa complex. The patient's Legionella urine antigen test was positive for L. pneumophila sg.1. During the field study, samples were taken from both the outdoor and indoor sea water-filled pools. Samples from the whirlpool were culture positive for L. pneumophila sg.1. Typing results indicated sea water isolate belonged to Sequence type ST82 and Allentown/France MAb subgroup. In vitro experiments showed that L. pneumophila strains are able to survive within sea water up to 7 days, and survival time is prolonged with sea water dilution. Also, our results indicate that L. pneumophila Allentown strain was the most resistant to adverse conditions in sea water with the highest values of DT50 (420 min) and DT90 (1,396 min). The possible source of infection was adding potable water for filling up the whirlpool. The survival of the L. pneumophila in additionally conditioned sea water should be considered in a further study.

Prevalence, genotyping and macrolide resistance of Mycoplasma pneumoniae among isolates of patients with respiratory tract infections, Central Slovenia, 2006 to 2014

In this retrospective study we employed real-time polymerase chain reaction (PCR) to analyse the occurrence of Mycoplasma pneumoniae among upper and lower respiratory tract infections (RTI) in the Central Region of Slovenia between January 2006 and December 2014. We also used a culture and pyrosequencing approach to genotype strains and infer their potential macrolide resistance. Of a total 9,431 tested samples from in- and out-patient with RTI, 1,255 (13%) were found to be positive by M. pneumoniae PCR. The proportion of positive samples was 19% (947/5,092)among children (≤16 years-old) and 7% (308/4,339) among adults (>16 years-old). Overall, among those PCR tested, the highest proportions of M. pneumonia infections during the study period were observed in 2010 and 2014. In these two years, 18% (218/1,237) and 25% (721/2,844) of samples were positive respectively,indicating epidemic periods. From the 1,255 M. pneumoniae PCR-positive samples, 783 (614 from paediatric and 169 from adult patients) were successfully cultured. Of these, 40% (312/783) were constituted of strains belonging to the P1 type II genomic group, while 60% (469/783) contained strains of the P1 type I group. Two isolates comprised both P1 type Iand II strains. Results of a genotype analysis by year,showed that the dominant M. pneumoniae P1 type during the 2010 epidemic was P1 type II (82% of isolates;81/99), which was replaced by P1 type I in the 2014 epidemic (75%; 384/510). This observation could indicate that the two epidemics may have been driven by a type shift phenomenon, although both types remained present in the studied population during the assessed period of time. Only 1% of strains (7/783) were found to harbour an A2063G mutation in the 23S rRNA gene,which confers macrolide resistance, suggesting that the occurrence of M. pneumoniae macrolide resistance still seems to be sporadic in our geographic area.

Epidemiological investigation of a legionellosis outbreak in a Slovenian nursing home, August 2010

BACKGROUND

August 2010 marked the beginning of the largest outbreak of legionellosis in a Slovenian nursing home. This article presents our experiences with the outbreak investigation.

METHODS

In order to collect the necessary patient epidemiological data, we used individual epidemiological questionnaires. Samples were available from 15 patients and were subject to laboratory investigation. Urine and sputum samples were difficult to obtain due to the underlying diseases of the patients. Serological diagnostics constituted an important part of the epidemiological investigation. Sixty-four environmental samples were taken to identify the sources of infection. By genotyping, we assessed the affinity of the allelic profile of Legionella pneumophila serogroup 1 in environmental samples and in patient samples.

RESULTS

Legionnaires' disease was diagnosed in 10 patients based on a combination of various tests. Legionella pneumophila serogroup 1, Legionella pneumophila serogroups 2-14, and Legionella sp., in concentrations of < 10 to 61,000 CFU/l, were isolated from 51 out of 64 environmental samples. The source of the outbreak was confirmed by genotyping the isolates from patients and the isolates from the water supply system. The 2 isolates had identical allelic profiles corresponding to that of L. pneumophila serogroup 1 allelic profile 2,3,9,10,2,1,6, designated sequence type 23 (according to the European Working Group for Legionella Infections).

CONCLUSION

We describe a Legionella pneumophila serogroup 1 outbreak in a Slovenian nursing home. The source of infection was demonstrated using sequence-based typing. Water flow disturbances were determined as the most probable cause of Legionella growth. Overall, the risk of a Legionella outbreak is underestimated in Slovenia.

Outbreak of Legionnaires' disease in a nursing home, Slovenia, August 2010: preliminary report

We report an outbreak of Legionnaires' disease ina nursing home in Slovenia in August 2010 affecting 15 of 234 residents. To date, Legionnaires' disease has been confirmed in four patients. Further serum analyses and genotyping of isolates are ongoing. The building's water distribution system with dead end sections has been identified as the probable source of infection.

Outbreak of Legionnaires' disease in a nursing home, Slovenia, August 2010: preliminary report

We report an outbreak of Legionnaires' disease in a nursing home in Slovenia in August 2010 affecting 15 of 234 residents. To date, Legionnaires' disease has been confirmed in four patients. Further serum analyses and genotyping of isolates are ongoing. The building's water distribution system with dead end sections has been identified as the probable source of infection.

Detection of point mutations in the gyrA gene of Helicobacter pylori isolates in Slovenia

BACKGROUND/AIMS

The prevalence of antibiotic-resistant H. pylori clinical isolates is a growing concern. So far, fluoroquinolones have not been used to treat H. pylori on a large scale, but recent studies have reported a high rate of quinolones-resistance in H. pylori too. The aim of our study was to asses the mechanism of resistance to ciprofloxacin in H. pylori clinical isolates from patients living in Slovenia.

METHODOLOGY

Out of 397 H. pylori clinical isolates, obtained in the period 1997 to 2004, 33 (8.3%) ciprofloxacin-resistant H. pylori isolates were recognized. DNA sequences of the gyrA gene were determined and translated into amino acid sequences.

RESULTS

Based on the results of this analysis, various point mutations in the ciprofloxacin-resistant clinical isolates were revealed. The most common mutations in H. pylori gyrA gene were found at codons corresponding to Asp91 (57.6%) and Asn87 (36.4%). Sequence analysis revealed amino acid substitutions also at codons Ala97 to Val, Ala129 to Thr and a double substitution at Asn87 to Lys and Val107 to Ile.

CONCLUSIONS

These results suggest that H. pylori resistance to ciprofloxacin is already present in the Slovenian population and that it seems to be mediated through amino acid substitutions in the gyrA gene. Furthermore, the results obtained from the study also demonstrate no significant association between the type of gyrA mutation and the ciprofloxacin MIC level.

Chlamydia trachomatis infections in heterosexuals attending sexually transmitted disease clinics in Slovenia

This study assessed the age and gender distribution of Chlamydia trachomatis infections among patients attending two clinics for sexually transmitted diseases (STDs) in Slovenia. Between January 1999 and December 2003, 1714 heterosexual male and 892 heterosexual female patients were tested for C. trachomatis. The prevalence of C. trachomatis infection was 19.5% (n = 334) for male patients and 10.7% (n = 96) for female patients, with the highest prevalence in the group aged 15-30 years. The prevalence decreased between 2000 and 2003 among female patients. The results support the implementation of routine screening for C. trachomatis genital infection among male and female patients aged < 30 years attending STD clinics in Slovenia.

Long-term Study of Chlamydophilosis in Slovenia

Immune reactivity for Chlamydophila (C.) psittaci in Slovenia was monitored in parrots, canaries, finches and nine species of recently captured free-living birds (house sparrows, Eurasian goldfinches, tree sparrows, chaffinches, European greenfinches, European serines, Eurasian siskins, Eurasian linnets and Eurasian bullfinches) in the period from 1991 to 2001. In subsequent years, specific IgG antibodies were found using immunofluorescence in parrots (0.7-53.6%), canaries (0.0-3.5%), finches (0.0-5.7%) and in captured free-living birds (33.3% of Eurasian goldfinches in 1994). An experimental infection with C psittaci was performed in order to study clinical signs and pathological changes in canaries and finches. The C. psittaci strain used for experimental infection was isolated from a cockatiel (Nymphicus hollandicus). Chlamydial DNA was extracted from clinical material followed by RFLP-PCR analysis. Infection of canaries and finches was confirmed in organ smears by direct immunofluorescence and a modified Gimenez staining method. In addition, serological tests of indirect immunofluorescence and complement fixation were applied. However, in spite of positive immunological reaction there were no clinical signs three weeks after infection. The present study includes results of a serological survey of persons belonging to the most important risk groups (breeders, pet shopkeepers and veterinarians). The results of microimmunofluorescence to identify the presence of specific antibodies and correlation between appearance of infection in birds and important risk groups are presented. Out of 143 persons belonging to the high-risk group we found 10 (7%) persons who were immunologically positive. Testing of two successive samples was used to demonstrate an increase in IgG and IgA titres in human sera. However, IgM, which is indicative of acute infection, could not be detected.

Presence of Chlamydia pneumoniae DNA in the artery wall--biomarker of coronary artery disease

Many authors have shown an association between Chlamydia pneumoniae (CPn) infection and coronary artery disease (CAD). However, whether CPn infection demonstrated by CPn DNA presence in the artery wall plays an important role in pathogenesis of CAD and acute coronary events (i.e. unstable angina) remains to be elucidated. One hundred and fifteen consecutive patients with CAD (51 with unstable angina and 64 with stable angina) were compared with 52 control subjects with aortic valve disease without angiographic evidence of CAD. The presence of CPn DNA in the aortic wall was assessed with nested polymerase chain reaction (PCR), and the IgM, IgG and IgA anti-CPn titres were assessed with microimmunofluorescence test. CPn DNA presence in the artery (i.e. aortic) wall was associated with 3.7-fold increased risk of CAD (95% CI 1.2-11.3, P < 0.01); however, no statistically significant difference in CPn DNA presence was demonstrated between unstable and stable angina (17.6% vs. 25%). In the CPn DNA positive group more often than in the CPn DNA negative group, serological signs of chronic infection (55.2% vs. 27%, P = 0.004) were demonstrated, whereas no statistically significant differences were demonstrated in prevalence of either acute infection (9.3% vs. 0%) or reinfection (0% vs. 0%). In conclusion, CPn DNA presence in the artery (i.e. aortic) wall was associated with CAD, therefore may be used as a biomarker for CAD. Moreover, no statistically significant differences in CPn DNA presence in the artery wall and in serology were present between unstable and stable angina; therefore, CPn infection does not seem implicated in triggering an acute coronary event.

Histopathologic signs for the inflammatory role of Chlamydia pneumoniae in the high-grade atherosclerotic coronary artery wall

The aim of the study was to prove the long-lasting and continuously harmful effect of chronic Chlamydia pneumoniae (CPn) infection on vessel walls in patients with diffuse coronary artery disease (CAD). In surgically obtained endarterectomized atherosclerotic plaques grade VI-VIII (Stary classification) from 10 patients with diffuse coronary artery disease and chronic (7) or past (3) CPn infection, signs of inflammatory response of the vessel wall on infectious agents were studied. In all 10 endarterectomized plaque step serial sections, immunologic signs of vessel wall response were present (positive T- and B-lymphocytes, macrophages, and capillarogenesis). In 8 of 10 patients' atherosclerotic plaque, unique features of active vasculitis in the neoarteriolar wall as well as arteriologenesis, were found. Seven of these 8 patients had serologically proven chronic CPn infection, and 1 had past infection. Features of vasculitis as well as arteriologenesis were absent in 2 patients who recovered from CPn infection at the time of surgery. In the endarterectomized segments of 3 randomly chosen patients in this study, the polymerase chain reaction method revealed positive DNA of CPn. Two of these patients had chronic infection, but the third had only a past CPn infection. This study provides evidence that CPn infection has continuous and a long-lasting inflammatory response in the high-grade atherosclerotic coronary artery vessel wall.

Prevalence of genital Chlamydia trachomatis infection in the general population of Slovenia: serious gaps in control

OBJECTIVES

One of the objectives of the first national survey of sexual lifestyles, attitudes, and health in Slovenia was to estimate the prevalence of and risk factors for genital Chlamydia trachomatis infection in Slovenian adults aged 18-49 years.

METHODS

Data were collected over 1999-2001 from a probability sample of the general population by face to face interviews and anonymous self administered questionnaires. Respondents were invited to provide a first void urine (FVU) specimen for polymerase chain reaction testing for C trachomatis infection. We compared the results to the equivalent British survey.

RESULTS

1447 individuals contributed FVU specimens (82.6% of survey respondents, 55.3% of those eligible). C trachomatis infection was diagnosed in 3.0% of men and 1.6% of women. Prevalence was highest in men and women aged 18-24 years (4.1% for both). Individuals reporting first heterosexual intercourse before the age of 16, unprotected sexual intercourse with at least one heterosexual partner during the preceding year, concurrent heterosexual relationships during the preceding year, and five or more lifetime heterosexual partners had a higher prevalence. The association was statistically significant only for five or more lifetime partners (adjusted OR 3.0; 95% CI 1.3 to 6.9; p = 0.01).

CONCLUSIONS

A relatively high prevalence of genital C trachomatis infection among 18-24 year old Slovenians, in the presence of relatively low risk sexual behaviour and low reported incidence rates of chlamydia infection, suggest serious gaps in the diagnosis and treatment of the condition. The results provide support for the introduction of chlamydia screening in Slovenia.

Chlamydia pneumoniae infection in Slovenian patients with diffuse coronary artery disease

Chlamydia pneumoniae (CP) infection might be involved in the pathogenesis of various forms of coronary artery disease (CAD), but there are no data about diffuse CAD with clinical picture of stable angina pectoris. Authors in a prospective study determined serum CP antibody levels (with MIF test) of 71 patients with coronarographically proven diffuse CAD and compared them to the age matched control group of the healthy Slovenian population. After azithromycin treatment in patients with chronic CP infection or reinfection, the CP antibody levels were determined again. A high percentage of chronic infection with CP was demonstrated (83.1%), and almost half (46.5%) of patients with diffuse CAD had reinfection or reactivation of chronic infection. A significantly higher prevalence of chronic CP infection was found in patients with diffuse CAD than in the healthy population (83.1% vs. 15.9%, p< 0.0001). After treatment with azithromycin, IgA seronegativity was achieved in 17.3%, in 23.1% the titer was lowered, however, in 57.7% of patients no change of antibody titers was found. In conclusion, a high prevalence of chronic infection with CP was found in patients with diffuse CAD. With azithromycin therapy, the eradication of chronic infection is difficult to achieve as well as to prove.

Aetiology and Clinical Presentation of Mild Community-Acquired Bacterial Pneumonia

A prospective study was initiated to analyse the bacterial aetiology and clinical picture of mild community-acquired pneumonia in Slovenia using the previously described Pneumonia Severity Index. Radiographically confirmed cases of pneumonia in patients treated with oral antibiotics in seven study centres were included. An aetiological diagnosis was attempted using culture of blood and sputum, urinary antigen testing for Streptococcus pneumoniae and Legionella pneumophila, and antibody testing for Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella pneumophila in paired serum samples. One hundred thirteen patients were evaluable for clinical presentation and 109 for aetiological diagnosis. At least one pathogen was detected in 62.4% patients. The most common causative agents were Mycoplasma pneumoniae in 24.8%, Chlamydia pneumoniae in 21.1%, and Streptococcus pneumoniae in 13.8% of patients. Dual infection was detected in 8.3% of patients. Most patients suffered from cough, fatigue, and fever. Patients with atypical aetiology of pneumonia differed from those with typical bacterial pneumonia or pneumonia of unknown aetiology in age, presence of dyspnea, and bronchial breathing on lung auscultation. Patients with pneumococcal, chlamydial, and mycoplasmal infections differed in age, risk class, presence of dyspnea, bronchial breathing, and proteinuria. There was an overlap of other clinical symptoms, underlying conditions, and laboratory and radiographic findings among the groups of patients classified by aetiology. Since patients with mild community-acquired pneumonia exhibit similar clinical characteristics and, moreover, since a substantial proportion of cases are attributable to atypical bacteria, broad-spectrum antibiotic treatment seems to be recommended.

Chlamydia pneumoniae infections in patients with community-acquired pneumonia in Slovenia

It is well known that Chlamydia pneumoniae is an important respiratory pathogen. In this study, the prevalence of specific antibodies to C. pneumoniae in hospitalized patients with community-acquired pneumonia (943 adult females, 990 adult males and 185 children) was evaluated over a period of 7 y (1993-99). Two serum samples were obtained from all of the patients: 1 on admission and the other 3 weeks later. The specimens were tested for C. pneumoniae IgG, IgM and IgA antibodies by means of a microimmunofluorescence test. Acute infection with C. pneumoniae was determined in 9.4% of females and 13.1% of males. In children and adolescent patients, the microimmunofluorescence test showed recent infection in 8.6% of cases, with the highest prevalence occurring in the 11-15 y age group. The highest prevalence of C. pneumoniae pneumonia was found in 1995 and 1999: 15.4% and 13.6% respectively. The results obtained showed that C. pneumoniae is persistently present in the population of Slovenia.

Feasibility of testing for Chlamydia trachomatis in a general population sexual behaviour survey in Slovenia

Our objective was to assess the feasibility of integrating first void urine (FVU) specimens testing for Chlamydia trachomatis genitourinary infection into a general population sexual behaviour survey. A total of 752 randomly selected respondents aged 18 to 54 were enrolled into the survey. Face to face interviewing with self-administered sensitive questions was used. Overall survey response rate was 77.4%. A convenience sub-sample of 83 respondents were invited to provide FVU specimens for confidential testing for C. trachomatis genitourinary infection. Fifty-five complied. This resulted in 66% FVU specimen participation rate among targeted respondents. Two specimens tested positive by Amplicor polymerase chain reaction. High feasibility study overall response rate indicated good acceptability of the survey. It proved feasible to collect FVU specimens for C. trachomatis testing in the small sub-sample. Consequently, we proceeded with integration of testing for C. trachomatis into the ongoing main survey.

Polymerase chain reaction for detection of Legionellae DNA in urine samples from patients with community-acquired pneumonia

Polymerase chain reaction (PCR) was used for detecting Legionella DNA in water, sputum, tracheal aspirate and bronchoalveolar lavage fluid. There is paucity of data on the use of PCR for detection of Legionella in serum and urine samples. In 82 patients admitted with community-acquired pneumonia, urinary PCR was used in addition to urinary antigen assay for Legionella pneumophila serogroup 1 and serological tests (indirect immunofluorescence and ELISA) in paired sera. PCR was positive in urine samples from 21 patients (26%): in six of seven patients with acute legionellosis by CDC criteria, and 15 patients with negative urine antigen showing no fourfold rise in antibody titers in immunofluorescence test.

Comparison of serologic tests with urinary antigen detection for diagnosis of legionnaires' disease in patients with community-acquired pneumonia

OBJECTIVE: To compare serologic methods and detection of urinary antigen in the diagnosis of community-acquired pneumonia. METHODS: Paired sera from 84 patients with community-acquired pneumonia were tested for Legionella pneumophila serogroup (LP SG) 1-7 and Legionella micdadei by use of the indirect immunofluorescence antibody test (IIF), enzyme-linked immunosorbent assay (ELISA) for LP SG 1-7 and complement-fixation (CF) test for LP SG 1. All patients were evaluated by ELISA urinary antigen detection for LP SG 1. RESULTS: Seven patients met the CDC criteria for acute Legionella infection, while in the rest of them we failed to detect urinary Legionella antigen. Thirty-three patients had non-diagnostic IIF antibody titers. Serum ELISA (IgG and/or IgM) was positive in 40 patients. Nine patients showed at least one CF titer of >/=1:32. The sensitivities of ELISA IgM for the first and the second serum samples compared with IIF were 42.8% and 46.6%, respectively, while the specificities were higher, i.e. 87% and 88.4%, respectively. The sensitivities of ELISA IgG for the first and the second samples were 42.8% and 53.3%, and the specificities were 77.9% and 76.8%, respectively. CONCLUSIONS: Although ELISA is simple to perform and easy to automate, we think that its advantages over indirect immunofluorescence and urinary antigen detection remain questionable.

Effect of rat (beta)-interferon on intracellular levels of hydrolases in rat embryonal fibroblasts (Wistar strain)

The effect of rat beta-interferon (IFN) on the intracellular level of thiole and acid proteases and alkaline phosphatases was investigated. When nontransformed rat embryonal fibroblasts (REF) (Wistar strain) were treated with homologous IFN, a time independent decrease of hydrolase enzyme levels was observed. IFN treatment of transformed cells lead to a time dependent decrease of thiole proteases within 90 min. The values for acid proteases remained unchanged after the short term IFN treatment.