Climatic Influences on Cryptococcus gattii [corrected] Populations, Vancouver Island, Canada, 2002-2004

Vancouver Island, Canada, reports the world's highest incidence of Cryptococcus gattii infection among humans and animals. To identify key biophysical factors modulating environmental concentrations, we evaluated monthly concentrations of C. gatti in air, soil, and trees over a 3-year period. The 2 study datasets were repeatedly measured plots and newly sampled plots. We used hierarchical generalized linear and mixed effect models to determine associations. Climate systematically influenced C. gattii concentrations in all environmental media tested; in soil and on trees, concentrations decreased when temperatures were warmer. Wind may be a key process that transferred C. gattii from soil into air and onto trees. C. gattii results for tree and air samples were more likely to be positive during periods of higher solar radiation. These results improve the understanding of the places and periods with the greatest C. gattii colonization. Refined risk projections may help susceptible persons avoid activities that disturb the topsoil during relatively cool summer days.

Ancient dispersal of the human fungal pathogen Cryptococcus gattii from the Amazon rainforest

Over the past two decades, several fungal outbreaks have occurred, including the high-profile ‘Vancouver Island’ and ‘Pacific Northwest’ outbreaks, caused by Cryptococcus gattii, which has affected hundreds of otherwise healthy humans and animals. Over the same time period, C. gattii was the cause of several additional case clusters at localities outside of the tropical and subtropical climate zones where the species normally occurs. In every case, the causative agent belongs to a previously rare genotype of C. gattii called AFLP6/VGII, but the origin of the outbreak clades remains enigmatic. Here we used phylogenetic and recombination analyses, based on AFLP and multiple MLST datasets, and coalescence gene genealogy to demonstrate that these outbreaks have arisen from a highly-recombining C. gattii population in the native rainforest of Northern Brazil. Thus the modern virulent C. gattii AFLP6/VGII outbreak lineages derived from mating events in South America and then dispersed to temperate regions where they cause serious infections in humans and animals.

Detection of Cryptococcus gattii in selected urban parks of the Willamette Valley, Oregon

Human and animal infections of the fungus Cryptococcus gattii have been recognized in Oregon since 2006. Transmission is primarily via airborne environmental spores and now thought to be locally acquired due to infection in non-migratory animals and humans with no travel history. Previous published efforts to detect C. gattii from tree swabs and soil samples in Oregon have been unsuccessful. This study was conducted to determine the presence of C. gattii in selected urban parks of Oregon cities within the Willamette Valley where both human and animal cases of C. gattii have been diagnosed. Urban parks were sampled due to spatial and temporal overlap of humans, companion animals and wildlife. Two of 64 parks had positive samples for C. gattii. One park had a positive tree and the other park, 60 miles away, had positive bark mulch samples from a walkway. Genotypic subtypes identified included C. gattii VGIIa and VGIIc, both considered highly virulent in murine host models.

Phenotypic antibiotic resistance of Escherichia coli and E. coli O157 isolated from water, sediment and biofilms in an agricultural watershed in British Columbia

This study examined the distribution of antibiotic resistant Escherichia coli and E. coli O157 isolated from water, sediment and biofilms in an intensive agricultural watershed (Elk Creek, British Columbia) between 2005 and 2007. It also examined physical and chemical water parameters associated with antibiotic resistance. Broth microdilution techniques were used to determine minimum inhibitory concentrations (MIC) for E. coli (n=214) and E. coli O157 (n=27) recovered isolates for ampicillin, cefotaxime, ciprofloxacin, nalidixic acid, streptomycin and tetracycline. Both E. coli and E. coli O157 isolates showed highest frequency of resistance to tetracycline, ampicillin, streptomycin and nalidixic acid; respectively. For E. coli, the highest frequency of resistance was observed at the most agriculturally-impacted site, while the lowest frequency of resistance was found at the headwaters. Sediment and river rock biofilms were the most likely to be associated with resistant E. coli, while water was the least likely. While seasonality (wet versus dry) had no relationship with resistance frequency, length of biofilm colonization of the substratum in the aquatic environment only affected resistance frequency to nalidixic acid and tetracycline. Multivariate logistic regressions showed that water depth, nutrient concentrations, temperature, dissolved oxygen and salinity had statistically significant associations with frequency of E. coli resistance to nalidixic acid, streptomycin, ampicillin and tetracycline. The results indicate that antibiotic resistant E. coli and E. coli O157 were prevalent in an agricultural stream. Since E. coli is adept at horizontal gene transfer and prevalent in biofilms and sediment, where ample opportunities for genetic exchange with potential environmental pathogens present themselves, resistant isolates may present a risk to ecosystem, wildlife and public health.

Campylobacter spp. distribution in biofilms on different surfaces in an agricultural watershed (Elk Creek, British Columbia): using biofilms to monitor for Campylobacter

Despite its relevance to public health, presence and concentrations of Campylobacter spp. in biofilms in natural aquatic environments has not been investigated. This study examined the occurrence of Campylobacter spp. in biofilms on a variety of surfaces (river rock, slate rock, wood, Lexan™, sandpaper, and sediment) and in water from December 2005 to December 2006 to find a substratum that facilitated campylobacters detection in natural aquatic environments. Samples were collected at four sites in an agricultural watershed (Elk Creek, British Columbia). Campylobacter spp. presence was determined using culturing methods. Correlations between chemical, physical and microbiological water quality parameters and Campylobacter spp. distribution on different surface types were also investigated. Campylobacter spp. had a prevalence of 13% in the wet season, but was not recovered in the dry season. Its prevalence was highest in sediment (27%), followed by slate rock (22%), Lexan and wood (13%), river rock (9%) and water (8%), respectively. No Campylobacter spp. was found in sandpaper biofilms. Several other criteria were used to assess substrata effectiveness, such as correlation amongst Campylobacter spp., indicator bacteria and water quality parameters, cost and availability of substratum, potential for standardizing substratum, ease of biofilm removal and probability of substratum loss in situ. Results show that sediment, slate rock or wood could be used as substrata for Campylobacter spp. monitoring. The study also highlights the potential use of nitrates and enterococci as faecal contamination indicators to protect public health.

Preventing airborne disease transmission: review of methods for ventilation design in health care facilities

Health care facility ventilation design greatly affects disease transmission by aerosols. The desire to control infection in hospitals and at the same time to reduce their carbon footprint motivates the use of unconventional solutions for building design and associated control measures. This paper considers indoor sources and types of infectious aerosols, and pathogen viability and infectivity behaviors in response to environmental conditions. Aerosol dispersion, heat and mass transfer, deposition in the respiratory tract, and infection mechanisms are discussed, with an emphasis on experimental and modeling approaches. Key building design parameters are described that include types of ventilation systems (mixing, displacement, natural and hybrid), air exchange rate, temperature and relative humidity, air flow distribution structure, occupancy, engineered disinfection of air (filtration and UV radiation), and architectural programming (source and activity management) for health care facilities. The paper describes major findings and suggests future research needs in methods for ventilation design of health care facilities to prevent airborne infection risk.

Cryptococcus gattii: an emerging fungal pathogen infecting humans and animals

Infectious fungi are among a broad group of microbial pathogens that has and continues to emerge concomitantly due to the global AIDS pandemic as well as an overall increase of patients with compromised immune systems. In addition, many pathogens have been emerging and re-emerging, causing disease in both individuals who have an identifiable immune defect and those who do not. The fungal pathogen Cryptococcus gattii can infect individuals with and without an identifiable immune defect, with a broad geographic range including both endemic areas and emerging outbreak regions. Infections in patients and animals can be severe and often fatal if untreated. We review the molecular epidemiology, population structure, clinical manifestations, and ecological niche of this emerging pathogen.

Respiratory health of two cohorts of terminal grain elevator workers studied 30 years apart

INTRODUCTION

We evaluated the respiratory health of two cohorts of grain terminal elevator workers who participated in one of either respiratory health surveys undertaken in 1978 and 2008.

METHODS

Questionnaire and spirometry data from 584 workers from the 1978 survey and 215 workers from the 2008 survey were compared using logistic regression and general linear modeling.

RESULTS

The geometric means of area samples of grain dust averaged 8.28 mg/m(3) in 1978 and 2.06 mg/m(3) in 2008. Workers in the 1978 survey had a significantly higher prevalence of respiratory symptoms (with the largest adjusted odds ratio of 3.78, 95% CI 2.07-7.25, for shortness of breath), a lower prevalence of atopic conditions and lower mean lung function.

CONCLUSION

Current grain workers had a lower risk of respiratory health consequences and a greater prevalence of atopic conditions than workers surveyed 30 years prior, most likely associated with reduced exposure to grain dust in the terminal elevator environment.

Surveillance for Cryptococcus gattii in horses of Vancouver Island, British Columbia, Canada

In the last decade Cryptococcus gattii has emerged as an important human and animal pathogen in southwestern British Columbia (BC), Canada. When the disease initially emerged it was identified in humans and multiple animal species on the east coast of Vancouver Island. From fall 2003 until summer 2004, active surveillance was initiated to look for horses exposed to or infected with the organism by performing nasal cultures and serum antigen testing in horses residing within 10 km of known areas of environmental reservoirs of the fungus. Surveillance efforts were facilitated by local equine practitioners who were also encouraged to report clinical cases. Nasal colonization was identified in four of the 260 horses tested but none had a serum cryptococcal antigen titer. All positive horses were from the same geographic area near Duncan, BC. During the study period, a single horse was diagnosed with systemic cryptococcosis and euthanized; clinical and post mortem information is described. As this organism continues to disseminate in the Pacific Northwest it is important for veterinarians to be familiar with the disease as early diagnosis may enable more effective treatment.

Cryptococcosis: update and emergence of Cryptococcus gattii

Cryptococcosis is a fungal disease that occurs throughout the world. Recent reclassification of Cryptococcus species along with a change in the distribution pattern has prompted reevaluation of the organism and the diseases caused by this pathogen. This review highlights the emergence of Cryptococcus gattii as a primary pathogen in North America and summarizes our current understanding of the disease in mammals and birds.

The emergence of Cryptococcus gattii in British Columbia and the Pacific Northwest

An unprecedented emergence of cryptococcal infections in animals and otherwise healthy humans was recognized in 1999 on the east coast of Vancouver Island, British Columbia. Unexpectedly, these infections were caused by Cryptococcus gattii, a species closely related to the AIDS-associated fungal pathogen Cryptococcus neoformans. Human cases have continued over the past 8 years and now total approximately 170 with eight deaths. Extensive environmental sampling, coupled with detailed molecular typing of isolates, revealed areas of permanent and transient colonization with primarily three genotypes of the fungus. C. gattii was found in air, soil, water, and in association with numerous tree species. Importantly, there is solid evidence for human-mediated dispersal of the pathogen, and C. gattii has now been detected in the environment on the mainland of British Columbia and in the Pacific Northwest. Associated animal and human cases are now being reported and further spread of the pathogen may be inevitable.

Spread of Cryptococcus gattii into Pacific Northwest region of the United States

This organism should be recognized as an emerging pathogen in the United States.

Cryptococcus gattii has emerged as a human and animal pathogen in the Pacific Northwest. First recognized on Vancouver Island, British Columbia, Canada, it now involves mainland British Columbia, and Washington and Oregon in the United States. In Canada, the incidence of disease has been one of the highest worldwide. In the United States, lack of cryptococcal species identification and case surveillance limit our knowledge of C. gattii epidemiology. Infections in the Pacific Northwest are caused by multiple genotypes, but the major strain is genetically novel and may have emerged recently in association with unique mating or environmental changes. C. gattii disease affects immunocompromised and immunocompetent persons, causing substantial illness and death. Successful management requires an aggressive medical and surgical approach and consideration of potentially variable antifungal drug susceptibilities. We summarize the study results of a group of investigators and review current knowledge with the goal of increasing awareness and highlighting areas where further knowledge is required.

Cryptococcus gattii: Emergence in Western North America: Exploitation of a Novel Ecological Niche

The relatively uncommon fungal pathogen Cryptococcus gattii recently emerged as a significant cause of cryptococcal disease in human and animals in the Pacific Northwest of North America. Although genetic studies indicated its possible presence in the Pacific Northwest for more than 30 years, C. gattii as an etiological agent was largely unknown in this region prior to 1999. The recent emergence may have been encouraged by changing conditions of climate or land use and/or host susceptibility, and predictive ecological niche modeling indicates a potentially wider spread. C. gattii can survive wide climatic variations and colonize the environment in tropical, subtropical, temperate, and dry climates. Long-term climate changes, such as the significantly elevated global temperature in the last 100 years, influence patterns of disease among plants and animals and create niche microclimates habitable by emerging pathogens. C. gattii may have exploited such a hitherto unrecognized but clement environment in the Pacific Northwest to provide a wider exposure and risk of infection to human and animal populations.

Biomarkers of airway acidity and oxidative stress in exhaled breath condensate from grain workers

RATIONALE

Grain workers report adverse respiratory symptoms due to exposures to grain dust and endotoxin. Studies have shown that biomarkers in exhaled breath condensate (EBC) vary with the severity of airway inflammation.

OBJECTIVES

The purpose of the study was to evaluate biomarkers of airway acidity (pH and ammonium [NH(4)(+)]) and oxidative stress (8-isoprostane) in the EBC of grain workers.

METHODS

A total of 75 workers from 5 terminal elevators participated. In addition to EBC sampling, exposure monitoring for inhalable grain dust and endotoxin was performed; spirometry, allergy testing, and a respiratory questionnaire derived from that of the American Thoracic Society were administered.

MEASUREMENTS AND MAIN RESULTS

Dust and endotoxin levels ranged from 0.010 to 13 mg/m(3) (median, 1.0) and 8.1 to 11,000 endotoxin units/m(3) (median, 610) respectively. EBC pH values varied from 4.3 to 8.2 (median, 7.9); NH(4)(+) values from 22 to 2,400 microM (median, 420); and 8-isoprostane values from 1.3 to 45 pg/ml (median, 11). Univariate and multivariable analyses revealed a consistent effect of cumulative smoking and obesity with decreased pH and NH(4)(+), and intensity of grain dust and endotoxin with increased 8-isoprostane. Duration of work on the test day was associated with decreased pH and NH(4)(+), whereas duration of employment in the industry was associated with decreased 8-isoprostane.

CONCLUSIONS

Chronic exposures are associated with airway acidity, whereas acute exposures are more closely associated with oxidative stress. These results suggest that the collection of EBC may contribute to predicting the pathological state of the airways of workers exposed to acute and chronic factors.

Dealing with waterborne disease in Canada: challenges in the delivery of safe drinking water

Protecting the public from waterborne diseases is an environmental health responsibility that every government worldwide must deal with. Canada's recent experience with waterborne outbreaks has brought the effectiveness of its water-monitoring and treatment systems under scrutiny. This paper focuses on microbial waterborne diseases and the shortcomings of drinking-water systems, dividing them into source control, monitoring, treatment, and operation, epidemiologic, and risk communication issues. Whereas some of these issues are often addressed, others, such as risk communication issues, are less frequently included in drinking water-management plans. Lessons can be learned from the Canadian experience, as these issues are applicable worldwide and especially in the developed world.

First contemporary case of human infection with Cryptococcus gattii in Puget Sound: evidence for spread of the Vancouver Island outbreak

We report a case of cryptococcosis due to C. gattii which appears to have been acquired in the Puget Sound region, Washington State. Genotyping confirmed identity to the predominant Vancouver Island genotype. This is the first documented case of human disease by the major Vancouver Island emergence strain acquired within the United States.

Cryptococcus gattii dispersal mechanisms, British Columbia, Canada

C. gattii may be spread through soil disturbances, wind, water, distribution of tree and soil byproducts, and human movement.

Recent Cryptococcus gattii infections in humans and animals without travel history to Vancouver Island, as well as environmental isolations of the organism in other areas of the Pacific Northwest, led to an investigation of potential dispersal mechanisms. Longitudinal analysis of C. gattii presence in trees and soil showed patterns of permanent, intermittent, and transient colonization, reflecting C. gattii population dynamics once the pathogen is introduced to a new site. Systematic sampling showed C. gattii was associated with high-traffic locations. In addition, C. gattii was isolated from the wheel wells of vehicles on Vancouver Island and the mainland and on footwear, consistent with anthropogenic dispersal of the organism. Increased levels of airborne C. gattii were detected during forestry and municipal activities such as wood chipping, the byproducts of which are frequently used in park landscaping. C. gattii dispersal by these mechanisms may be a useful model for other emerging pathogens.

Spread of Cryptococcus gattii in British Columbia, Canada, and detection in the Pacific Northwest, USA

Cryptococcus gattii, emergent on Vancouver Island, British Columbia (BC), Canada, in 1999, was detected during 2003-2005 in 3 persons and 8 animals that did not travel to Vancouver Island during the incubation period; positive environmental samples were detected in areas outside Vancouver Island. All clinical and environmental isolates found in BC were genotypically consistent with Vancouver Island strains. In addition, local acquisition was detected in 3 cats in Washington and 2 persons in Oregon. The molecular profiles of Oregon isolates differed from those found in BC and Washington. Although some microclimates of the Pacific Northwest are similar to those on Vancouver Island, C. gattii concentrations in off-island environments were typically lower, and human cases without Vancouver Island contact have not continued to occur. This suggests that C. gattii may not be permanently colonized in off-island locations.

Characterization of environmental sources of the human and animal pathogen Cryptococcus gattii in British Columbia, Canada, and the Pacific Northwest of the United States

Cryptococcus gattii has recently emerged as a primary pathogen of humans and wild and domesticated animals in British Columbia, particularly on Vancouver Island. C. gattii infections are typically infections of the pulmonary and/or the central nervous system, and the incidence of infection in British Columbia is currently the highest reported globally. Prior to this emergence, the environmental distribution of and the extent of colonization by C. gattii in British Columbia were unknown. We characterized the environmental sources and potential determinants of colonization in British Columbia. C. gattii was isolated from tree surfaces, soil, air, freshwater, and seawater, and no seasonal prevalence was observed. The C. gattii concentrations in air samples were significantly higher during the warm, dry summer months, although potentially infectious propagules (<3.3 microm in diameter) were present throughout the year. Positive samples were obtained from many different areas of British Columbia, and some locations were colonization "hot spots." C. gattii was generally isolated from acidic soil, and geographic differences in soil pH may influence the extent of colonization. C. gattii soil colonization also was associated with low moisture and low organic carbon contents. Most of the C. gattii isolates recovered belonged to the VGIIa genetic subtype; however, sympatric colonization by the VGIIb strain was observed at most locations. At one sampling site, VGIIa, VGIIb, VGI, and the Cryptococcus neoformans serotype AD hybrid all were coisolated. Our findings indicate extensive colonization by C. gattii within British Columbia and highlight an expansion of the ecological niche of this pathogen.

Methanol exposure to car occupants from windshield washing fluid: a pilot study

Automobile occupants might be exposed to considerable amounts of methanol from previously unreported source, namely via the inhalation of vapors of winter-grade, methanol-based, windshield washing fluid that drains to the intake air ducts of the car. Air samples were collected in passenger cars during simulated operating conditions and analyzed for methanol via headspace gas chromatography-mass spectrometry, electron impact, selected ion monitoring. The method was linear in the 2-2000 ppm range. Concentrations exceeding 1000 ppm were recorded.

PRACTICAL IMPLICATIONS

Using a winter-grade, methanol-based, windshield washing fluid for windshield cleaning in a passenger car can result in a methanol concentration in the air of the passenger cabin in excess of 1000 ppm. In view of the widespread use of this product, more studies are necessary to elucidate, in depth, the concentrations of methanol vapors which could be encountered in various weather and driving conditions as well as the concomitant contributing influences of car design. These studies are necessary to properly assess the hazards associated with use of the fluid and possible mitigation approaches which might include substitution of methanol by less toxic formulations.

Follow-up study of dogs and cats with asymptomatic Cryptococcus gattii infection or nasal colonization

The pathogenesis of Cryptococcus spp. infection following nasal colonization is unclear. This article reports follow-up data on a cohort of seven cats and five dogs identified in a previous study as sub-clinically infected with Cryptococcus spp. or colonized by C. gattii. Two cats progressed to clinical disease within four to six months of initial detection of antigenemia and nasal cavity colonization. The ten other animals remained asymptomatic but many were repeatedly positive on cryptococcal antigen testing or nasal fungal culture suggesting protracted infection or colonization. The results indicate that asymptomatically infected animals may clear the organism, remain sub-clinically infected or progress to clinical disease. Factors influencing the transition from exposure to disease require further investigation.

Sub-clinical infection and asymptomatic carriage of Cryptococcus gattii in dogs and cats during an outbreak of cryptococcosis

Since 1999, Cryptococcus gattii has emerged as an important pathogen of humans and animals in British Columbia, Canada. Nasal swabs and serum samples were collected from dogs and cats residing within the Coastal Douglas Fir biogeoclimatic zone on Vancouver Island, where clinical cases have been reported. Deep and superficial nasal fungal cultures of 280 dogs and 94 cats identified four (4.3%) cats and three (1.1%) dogs with C. gattii serotype B in their nasal cavity. Serum samples collected from 266 dogs and 84 cats identified six (7.1%) cats and two (0.8%) dogs with a positive cryptococcal antigen titer. Overall cats were 4.4 times more likely than dogs to be positive on one or both tests. Identification of sub-clinical infection and nasal colonization is an important step in the characterization of the outbreak of clinical cryptococcosis on Vancouver Island.

Comparative gene genealogies indicate that two clonal lineages of Cryptococcus gattii in British Columbia resemble strains from other geographical areas

Cryptococcus gattii has recently emerged as a pathogen of humans and animals in the temperate climate of Vancouver Island, British Columbia (B.C.). The majority (approximately 95%) of the isolates from the island belong to the VGII molecular type, and the remainder belong to the VGI molecular type. The goals of this study were to compare patterns of molecular variation among C. gattii isolates from B.C. with those from different areas of the world and to investigate the population structure using a comparative gene genealogy approach. Our results indicate that the C. gattii population in B.C. comprises at least two divergent lineages, corresponding to previously identified VGI and VGII molecular types. The genealogical analysis of strains suggested a predominantly clonal population structure among B.C. isolates, while there was evidence for sexual recombination between different molecular types on a global scale. We found no geographic pattern of strain relationships, and nucleotide sequence comparisons revealed that genotypes among isolates from B.C. were also present among isolates from other areas of the world, indicating extensive strain dispersal. The nucleotide sequence diversity among isolates from B.C. was similar to that among isolates from other areas of the world.

Effect of heat-treatment and the role of phospholipases on Fungizone®-induced cytotoxicity within human kidney proximal tubular (HK-2) cells and Aspergillus fumigatus

The objectives of this study were to determine the effects of heat-treatment on Fungizone (FZ)-induced cytotoxicity in human kidney (HK-2) cells and fungal isolates of Aspergillus fumigatus, and to determine the possible role of phospholipases (PLA2 and PLC) on heat-treated FZ (HFZ)-associated renal cell toxicity. HK-2 cells were grown at 37 degrees C in T75 flasks and seeded in 96-well plates at 20,000 cells/well. FZ and HFZ concentrations of 10, 25 and 50 microg/mL of AmpB were prepared. Snake venom PLA2 and PLC (2.15 U/mL) were pre-incubated with HFZ for 1h prior to addition to the cells. After 18 h of incubation, an MTS assay was performed to assess cell viability through mitochondrial respiration. A spore suspension of A. fumigatus was prepared and 96-well plates were seeded at 500,000 spores/well. HFZ and FZ were prepared as above and incubated with the fungi at 35 degrees C. After 72 h, the minimum inhibitory concentration (MIC) was determined as the lowest concentration of drug that inhibited visible growth. Student-Newman-Keuls multiple comparisons tests were conducted to determine statistical significance. FZ-induced cytotoxicity was significantly greater than for HFZ in HK-2 cells at amphotericin B (AmpB) concentrations between 10 and 50 microg AmpB/mL (n = 5-9, p < 0.05). HFZ and FZ were found to have similar minimum inhibitory concentration (MIC) ranges for A. fumigatus (0.225-0.25 microg) AmpB/mL; (n = 6). The addition of PLA2 and PLC to 50 microg heat-treated AmpB/mL significantly enhanced the cytotoxicity compared to controls (n = 6, p < 0.05). The presence of the phospholipases did not alter FZ-associated renal cell toxicity. Taken together, these findings suggest heat-treatment significantly decreased FZ-induced cytotoxicity in HK-2 cells without altering toxicity against a reference strain of A. fumigatus. In addition, PLA2 and PLC enhanced the renal toxicity associated with HFZ, but not that of FZ.

Reduction in the bactericidal activity of selected cathelicidin peptides by bovine calf serum or exogenous endotoxin

Synthetic cathelicidin peptides exhibit enhanced antimicrobial action and avid binding to LPS, thereby detoxifying the action of endotoxin released from degrading bacteria. A series of cathelicidin antimicrobial peptide (CAP) and sheep myeloid antimicrobial peptide (SMAP) congeners were examined to determine whether LPS-binding could predict other beneficial characteristics of the peptides. The peptides were challenged in complex media with bovine calf serum or LPS, and their ability to kill the Gram negative pathogens Klebsiella pneumoniae (ATCC 43816) or Pseudomonas aeruginosa (PA103) was then assessed. LPS-binding efficiency was not correlated with antimicrobial activity in complex media. Additionally, LPS- and serum-binding may interfere with the antimicrobial activity of peptides in complex media.

Clinicopathologic features of an unusual outbreak of cryptococcosis in dogs, cats, ferrets, and a bird: 38 cases (January to July 2003)

OBJECTIVE

To determine clinical and pathologic findings associated with an outbreak of cryptococcosis in an unusual geographic location (British Columbia, Canada).

DESIGN

Retrospective study.

ANIMALS

1 pink-fronted cockatoo, 2 ferrets, 20 cats, and 15 dogs.

PROCEDURE

A presumptive diagnosis of cryptococcosis was made on the basis of serologic, histopathologic, or cytologic findings, and a definitive diagnosis was made on the basis of culture or immunohistochemical staining.

RESULTS

No breed or sex predilections were detected in affected dogs or cats. Eleven cats had neurologic signs, 7 had skin lesions, and 5 had respiratory tract signs. None of 17 cats tested serologically for FeLV yielded positive results; 1 of 17 cats yielded positive results for FIV (western blot). Nine of 15 dogs had neurologic signs, 2 had periorbital swellings, and only 3 had respiratory tract signs initially. Microbiologic culture in 15 cases yielded 2 isolates of Cryptococcus neoformans var grubii (serotype A) and 13 isolates of C. neoformans var gattii (serotype B); all organisms were susceptible to amphotericin B and ketoconazole. Serologic testing had sensitivity of 92% and specificity of 98%.

CONCLUSIONS AND CLINICAL RELEVANCE

Serologic titers were beneficial in identifying infection in animals with nonspecific signs, but routine serum biochemical or hematologic parameters were of little value in diagnosis. Most animals had nonspecific CNS signs and represented a diagnostic challenge. Animals that travel to or live in this region and have nonspecific malaise or unusual neurologic signs should be evaluated for cryptococcosis.

A rare genotype of Cryptococcus gattii caused the cryptococcosis outbreak on Vancouver Island (British Columbia, Canada)

Cryptococcus gattii causes life-threatening infection of the pulmonary and central nervous systems in hosts with normal immunity and traditionally has been considered to be restricted geographically to tropical and subtropical climates. The recent outbreak of C. gattii in the temperate climate of Vancouver Island, BC, Canada, led to a collaborative investigation. The objectives of the current study were to ascertain the environmental source of the outbreak infections, survey the molecular types of the outbreak and environmental cryptococcal isolates, and determine the extent of genetic diversity among the isolates. PCR-fingerprinting and amplified fragment length polymorphism (AFLP) were used to examine the genotypes, and mating assays were performed to determine the mating type of the isolates. All outbreak and environmental isolates belonged to C. gattii. Concordant results were obtained by using PCR-fingerprinting and AFLP analysis. The vast majority of clinical and veterinary infections were caused by isolates of the molecular type VGII/AFLP6, but two were caused by molecular type VGI/AFLP4. All environmental isolates belonged to molecular type VGII/AFLP6. Two or three subtypes were observed within VGII/AFLP6 among outbreak and environmental isolates. All mating-competent isolates were of the alpha-mating type. The emergence of this usually tropical pathogen on Vancouver Island highlights the changing distribution of this genotype and emphasizes the importance of an ongoing collaborative effort to monitor the global epidemiology of this yeast.

A field comparison of four fungal aerosol sampling instruments: inter-sampler calibrations and caveats

Four bioaerosol samplers (Reuter Centrifugal, Andersen N6 Single Stage, Surface Air System Super 90, and Air-o-Cell) were used to take c. 300 side-by-side measurements at 75 public building sites. Regression models were developed to examine the relationships between each method pair. The models demonstrate that measurements from these instruments are not directly comparable, requiring inter-instrument calibration. Sampling location (indoor vs. outdoor) was a confounder in all the pairwise comparisons between samplers. In addition, the slopes of the relationships between all method pairs except one differed in indoor vs. outdoor locations. These results emphasize that direct comparisons between methods should not be undergone without prior calibration. Where measurement circumstances are similar to those of this study, the regression models might serve as a basis to convert measurements made with one instrument to those made with another. However, the robustness and generalizability of the models in different measurement settings needs to be assessed.

PRACTICAL IMPLICATIONS

Many different bioaerosol sampling devices are in common use for indoor air quality studies. If data from research studies are to be compared, an approximation of the relationships between the equipment would be useful. A comparison of three culturable sampling devices (Andersen N6, SAS 90, RCS) and one particulate sampling device (Air-o-Cell) collecting simultaneous samples under field conditions showed high linear correlations between methods. However, while direct comparisons between sampling data were not possible, the regression models reported here explained 60-85% of the variance in fungal concentrations, and underscored the importance of the effect of environment on measurement.

Evaluation and determinants of airborne bacterial concentrations in school classrooms

A survey of 39 elementary schools was undertaken to determine indoor air concentrations of bioaerosols within a coastal, temperate climatic zone in British Columbia, Canada. This article reports the results for airborne bacteria. Determinants of exposure were grouped into environmental (outdoor temperature, relative humidity, season, weather), ventilation and comfort parameter (indoor relative humidity, temperature, indoor CO2 concentration, indoor fungal concentration), and occupancy (number of occupants, activity levels, occupancy patterns) variables. Regression modeling was used to evaluate the association between these factors and measured concentrations of indoor mesophilic bacteria. Naturally ventilated rooms (47% of the total rooms surveyed) had higher bacterial counts than mechanically ventilated rooms (geometric mean 325 vs. 166 CFU/m3, respectively, p < 0.001). In univariate analyses, bacterial counts were negatively correlated with supply and exhaust flow rates, air exchange rates, and the percentage of the day that occupants spent quietly sitting at their desks. Analysis of bacterial groups indicated various sources of the bacterial aerosol, with micrococci and staphylococci closely associated with occupancy variables, Bacillus with site and occupancy, and coryneform bacteria with site variables only. Approximately 60% of the variance in the outcome measurement of total bacteria was accountedfor by indoor CO2, lower air exchange rate, the age of the building, signs of current or old moisture stains, room volume, indoor relative humidity, and occupant activity level in a multiple linear regression model, with ventilation factors accounting for 40% of the variance.

A field comparison of four samplers for enumerating fungal aerosols I. Sampling characteristics

This study compared the performance of four bioaerosol samplers, the Reuter Centrifugal Air Sampler, the Andersen N6 single stage, the Surface Air System 90, and the Air-o-Cell, in measurements for airborne fungal propagules collected in 75 public building sites without prior knowledge of water damage or mold problems in British Columbia, Canada. The samplers had differences in detection limits, reproducibility, and overall yield. However, high and significant correlations between samplers (indoor samples: Pearson r = 0.60-0.85, P < 0.001) suggest that relative performances between samplers were reasonably consistent. These results indicate that fungal airborne concentration data are dependent on the methods used for assessment, and introduce additional variability in exposure assessment studies.

PRACTICAL IMPLICATIONS

In the absence of a standard protocol for sampling bioaerosols, the interpretation of aerosol data reported in indoor air quality studies is entirely dependent on an appreciation of the sampling characteristics of commonly used instrumentation. Although a number of comparative studies have been undertaken in the laboratory, only a few studies have made reported comparison data under field conditions. This study compared three culturable sampling devices, the Andersen N6, SAS 90, and RCS, and one particulate sampling device, the Air-o-Cell, in offices and public areas in a variety of buildings, under conditions of forced air or natural ventilation. The concentrations of fungal aerosols collected during simultaneous sample collection were highly correlated, yet varied by orders of magnitude. The performance of these devices must be carefully considered before a standard protocol can be promulgated.

Evaluation and a Predictive Model of Airborne Fungal Concentrations in School Classrooms

Exposure to airborne fungal products may be associated with health effects ranging from non-specific irritation of the respiratory tract or mucus membranes to inflammation provoked by specific fungal antigens. While concentrations of airborne fungi are frequently measured in indoor air quality investigations, the significance of these measurements in the absence of visual mold colonization is unclear. This study was undertaken to evaluate concentrations of airborne fungal concentrations in school classrooms within a defined geographic location in British Columbia, Canada, and to build a model to clarify determinants of airborne fungal concentration. All elementary schools within one school district participated in the study. Classrooms examined varied by age, construction and presence or absence of mechanical ventilation. Airborne fungal propagules were collected inside classrooms and outdoors. Variables describing characteristics of the environment, buildings and occupants were measured and used to construct a predictive model of fungal concentration. The classrooms studied were not visibly contaminated by fungal growth. The data were evaluated using available guidelines. However, the published guidelines did not take into account significant aspects of the local environment. For example, there was a statistically significant effect of season on the fungal concentrations and on the proportional representation of fungal genera. Rooms ventilated by mechanical means had significantly lower geometric mean concentrations than naturally ventilated rooms. Environmental (temperature, outdoor fungal concentration), building (age) and ventilation variables accounted for 58% of the variation in the measured fungal concentrations. A methodology is proposed for the evaluation of airborne fungal concentration data which takes into account local environmental conditions as an aid in the evaluation of fungal bioaerosols in public buildings.

Point-of-sale glass bottle recycling: indoor airborne exposures and symptoms among employees

AIMS

To assess the impact of newly introduced point-of-sale glass bottle recycling on indoor air quality and employee health.

METHODS

Airborne exposures and both chronic and acute respiratory and somatic symptoms were surveyed among 226 employees at 36 randomly selected liquor stores with bottle recycling and in-house glass breaking. Each store was visited twice; between visits glass breaking was discontinued for one month in half the stores (selected at random), although bottles were still collected and stored on site. Rates of chronic symptoms were compared to an external, unexposed control population.

RESULTS

Geometric mean exposure levels were 0.18 mg/m3 for inhalable particulate matter and 3.6 EU/m3 for endotoxin (270 personal samples); 1064 CFU/m3 for viable fungi (648 area samples). Fungal levels were associated with visibly mouldy bottles being broken, outdoor fungal counts, and uncovered glass bins. Exposures were not altered by the intervention of shutting down glass breaking machinery. Compared to controls, employees reported more work related chronic chest tightness and chronic nasal symptoms. Acute chest symptoms were associated with breaking visibly mouldy bottles, but not with measured fungal counts. Inhalable particulate matter levels >0.2 mg/m3 were associated with acute upper airway irritation. Somatic symptoms were associated with measures of psychosocial job strain.

CONCLUSION

Results suggest that this type of recycling programme may generate fungal exposures sufficient to elicit upper airway and chest symptoms.

Modeling of occupant-generated CO2 dynamics in naturally ventilated classrooms

A numerical method is presented to estimate the concentration of occupant-generated CO(2) for the (time-varying) occupancy typically found in nonforced ventilated elementary school classrooms. Here, the governing mass balance was solved numerically and compared to experimental measurements in order to estimate the respiration and (time-varying) infiltration rates. For the cases studied, we estimate an average CO(2) generation rate per child as 404 mg/min(-1). This is similar to estimates found in the literature for the age and activity level of elementary students, the classroom occupants. The average estimated infiltration rates were found to be larger than those measured from the decay of the tracer gas SF(6) under closed-door static conditions. The in-use infiltration rates were increased by additional air exchange due to people entering and leaving the room. In addition, we show that the difference (or error) between the instantaneous concentration of CO(2) and the time-averaged value recorded by a data-logging CO(2) monitor varies depending on the infiltration rate and sampling time. Therefore, the time interval selected for averaging may increase the overall error of the apparent CO(2) concentration. We conclude that the methods used to measure air exchange rates in naturally ventilated rooms underestimate the actual ventilation rate of a room under "in-use" conditions. However, even with the addition of uncontrolled outdoor air, the concentration of CO(2) in the classrooms studied was higher than recommended to meet air quality objectives.

Novispirin G10-induced lung toxicity in a Klebsiella pneumoniae infection model

Mammalian cathelicidins are a class of innate antimicrobial peptides isolated from leukocytes and epithelial cells that aid host defense against bacterial infections. Synthetic analogs of cathelicidins offer the promise of potent broad-spectrum antimicrobial efficacy. We developed a combined lung infection and ex vivo whole-blood assay model to characterize the toxicity and efficacy of synthetic cathelicidin-derived peptides. Male C57BL/6 mice were administered saline or Klebsiella pneumoniae by intratracheal instillation. Five hours later, the Klebsiella-infected mice were instilled with saline, tobramycin (1 mg/kg of body weight or 10 mg/kg), novispirin G10 (0.4 mg/kg), or a combination of tobramycin (1 mg/kg) and G10 (0.4 mg/kg). At 24 h, bronchoalveolar lavage fluid (BAL) was collected for analysis of culturable bacteria and for markers of inflammation and lung toxicity. Blood samples were analyzed for circulating cytokines. Recovery of Klebsiella from the lung, recruitment of neutrophils, and production of interleukin-6 (IL-6) in BAL samples were highly correlated (r=0.68 and 0.84, respectively; P<0.01). Animals treated with G10 or G10 plus tobramycin had increased hemoglobin (P<0.001) and protein (P<0.001) levels compared to those for Klebsiella-infected or tobramycin-alone-treated animals. The levels of circulating IL-6 in mice infected with Klebsiella were 1000- to 10,000-fold higher than in the noninfected controls. The highest levels of IL-6 were measured in mice given G10 alone or in combination with tobramycin. These studies demonstrated that G10 was relatively nontoxic in saline-treated mice but was highly toxic in mice infected with Klebsiella. This finding establishes the importance of investigating candidate antimicrobial agents in an in vivo infection model.

Beta(1-->3)-glucan exposure levels among workers in four British Columbia sawmills

Beta(1-->3)-glucans were extracted from wood dust samples taken during the summer of 1997 at four British Columbia sawmills. Personal dust samples were collected using a GSP-sampler for inhalable dust and the sampling strategy targeted all production and maintenance jobs at least once at each mill. Potential exposure determinants data were documented concurrently, including weather conditions, log storage methods, wood conditions, species, production level, jobs and tasks. beta(1-->3)-glucans were measured by enzyme inhibition immunoassay (EIA). A total of 223 personal beta(1-->3)-glucan samples were analyzed. 45.7% were below the limit of detection (LOD). Geometric mean concentration ranged from 3.5 to 18.9 micro g/m(3) across the four mills. The highest levels were measured at the Interior mills, particularly in the log processing and sawmill areas. Multivariate regression models indicated that land-based log storage, clean-up jobs, high wood dust concentration, lumber yard department and the interaction between land-based log storage method and log processing department were associated with increased beta(1-->3)-glucan concentration.

Evaluation of five extraction protocols for quantification of endotoxin in metalworking fluid aerosol

OBJECTIVES

Occupational exposures to endotoxin-contaminated, water-based metalworking fluids (MWFs) are thought to contribute to cases of respiratory illness. Before occupational exposure limits for endotoxin can be proposed, accuracy and reproducibility of laboratory measurements must be established. The method most commonly used to quantify endotoxin is the Limulus amebocyte lysate (LAL) assay and this is the basis for the American Society for Testing and Materials (ASTM) method E2144-01. This study was conducted to generate multiple samples with similar mass and endotoxin loading in order to compare four alternative extraction methods with the ASTM method.

METHODS

Using an exposure chamber system that provides a uniform distribution of MWF mist, aerosols with three concentrations of endotoxins (4.5, 350 and 1141 EU/m(3)) were collected simultaneously on multiple filter samples. The filters were examined for endotoxin concentration using five different extraction protocols: extraction with 1 h shaking at 25 degrees C in 30 ml pyrogen-free water (PFW) (protocol 1) or in PFW with 0.05% Tween-20 (protocol 2); or shaking at 68 degrees C in 30 ml PFW (protocol 3) or PFW with Tween-20 (protocol 4); or extraction into 20 ml PFW with sonication at 25 degrees C and pH adjustment to 7.5 (ASTM protocol).

RESULTS

The uniformity of the aerosol mass yielded coefficients of variation of 12.7, 7.7 and 1.4% for the low, medium and high exposure groups, respectively. The variance in the endotoxin extraction protocols was highest for the ASTM method for the low, medium and high concentration trials. Low, medium and high endotoxin groups were statistically different (P < 0.001), but there were no statistical differences between extraction protocols within these exposure levels.

CONCLUSIONS

ASTM method E2144-01 yielded comparable estimations of MWF endotoxin aerosol concentrations but with higher variability than the four other extraction methods. This study shows that extraction into PFW at 25 degrees C with or without Tween-20 was an improvement over the ASTM method in that the estimation was more precise and the method is simpler.

Application of a modified bioassay for monitoring serum teicoplanin and vancomycin in febrile neutropenic patients

Teicoplanin is a glycopeptide antibiotic with a mode of action and spectrum of activity similar to those of vancomycin. Its efficacy and tolerability as empiric therapy and its pharmacokinetic properties in neutropenic patients are being studied in a double-blinded, randomized trial in comparison with those of vancomycin. We report here a modified agar diffusion bioassay which is suitable for monitoring levels of either teicoplanin or vancomycin in serum during combination therapy with beta-lactams, aminoglycosides, and amphotericin B. Serum samples spiked with either teicoplanin or vancomycin gave reproducible results (mean coefficient of variation, 8.8%) regardless of the presence of tobramycin, amikacin, piperacillin, ceftazidime, amphotericin B, or their combinations. Among 25 patients who received teicoplanin at a dosing schedule of 6 mg/kg every 24 h intravenously, steady state was reached after 14.2 +/- 4.0 days, and 1-h peak and trough concentrations of teicoplanin in serum at steady state were 40.8 +/- 15.0 and 12.5 +/- 3.2 mg/liter, respectively. In contrast, among 25 patients who received vancomycin at a dosing schedule of 15 mg/kg every 12 h intravenously, steady state was reached by 24 h, and the 1-h peak and trough concentrations in serum were 37.5 +/- 15.6 and 8.3 +/- 3.8 mg/liter, respectively. The elimination half-lives for teicoplanin estimated by two separate approaches agreed closely with each other: 80.5 +/- 21.5 h by an accumulation model (M. Gilbaldi and D. Perrier, Pharmacokinetics, 2nd ed., p. 121, 1982) and 87.3 +/- 19.3 h as predicted from the degree of renal function (M. Rowland, Clin. Pharmacokinetic 18:184-209, 1990). These values were 14- to 15-fold higher than that for vancomycin (5.6 +/- 1.8 h). Since considerable variability was noted in the pharmacokinetic parameters for both teicoplanin and vancomycin among the individual patients, our data further emphasized the need for frequent monitoring of these drugs during empiric therapy of the febrile neutropenic patient.

Colony immunoblot assay for the detection of staphylococcal toxic shock syndrome toxin 1 (TSST-1) with anti-TSST-1 F(ab')2 fragments

Toxic shock syndrome toxin 1 (TSST-1), an exoprotein of Staphylococcus aureus, is strongly implicated in the pathogenesis of TSS. Detection of TSST-1, however, is often hindered in immunoassays because of the cosecretion of protein A, a genetic trait which appears to be coordinately expressed with other exoproteins in S. aureus. We developed a colony immunoblot assay for rapid screening of TSST-1-producing S. aureus using TSST-1-specific rabbit F(ab')2 fragments. The sensitivity and specificity of this method were compared with those of a quantitative noncompetitive enzyme-linked immunosorbent assay (ELISA) for 34 S. aureus isolates (17 TSS-associated and 17 non-TSS-associated isolates). Cosecreted protein A in culture supernatants was evaluated by a quantitative competitive ELISA. The results clearly indicated the superiority of F(ab')2 fragments in eliminating nonspecific reactivity of protein A in the colony immunoblot assay. The sensitivity of the immunoblot with TSST-1-specific F(ab')2 was similar to that with whole immunoglobulin G (94 versus 82%, respectively; P = 0.601, Fisher's exact test), but the specificity was markedly improved (94 versus 59%, respectively; P = 0.039). Among TSST-1-negative isolates (as determined by ELISA), strains which gave false-positive results in the immunoglobulin G immunoblot assay produced higher amounts of protein A than strains which gave true-negative results (P = 0.08, Mann-Whitney rank sum test, one tailed). Among strains positive for TSST-1, the level of TSST-1 detected in culture supernatants correlated inversely with the amount of protein A secreted (rs = -0.64; P less than 0.01, Spearman rank correlation). These findings validate the utility of a rapid screening method for the detection of TSST-1-producing S. aureus and support the concept of coordinate secretion of exoproteins in S. aureus.

Cross-resistance of Pseudomonas aeruginosa to ciprofloxacin, extended-spectrum beta-lactams, and aminoglycosides and susceptibility to antibiotic combinations

The susceptibilities of 270 clinical isolates of Pseudomonas aeruginosa from diverse sources (82 burn patients, 76 cystic fibrosis [CF] patients, and 112 other sources) to ciprofloxacin and three other quinolones, nine extended-spectrum beta-lactams, and three aminoglycosides were determined by an agar dilution method in cation-supplemented Mueller-Hinton medium. Ciprofloxacin, ceftazidime, imipenem, and aztreonam were the most active. MICs for burn isolates were consistently higher than those for other isolates for most antibiotics, whereas those for CF strains were consistently lower. Multidrug resistance to aminoglycosides and beta-lactams occurred in 21% of the burn isolates, 2.6% of the CF isolates, and 8.9% of the other isolates. Ninety percent of these strains remained susceptible to ciprofloxacin. Seven percent of the isolates were resistant to ciprofloxacin (MIC, greater than or equal to 2 micrograms/ml). Concurrent resistance to ciprofloxacin and beta-lactams or aminoglycosides was rare (1.8 to 4%). Analysis by Spearman rank correlation revealed a high degree of correlation of MICs among antibiotics within the same class, except for imipenem. An inoculum effect was observed for all antibiotics between 10(6) and 10(4) CFU (P less than 0.05), with those for piperacillin and cefoperazone being the most pronounced (16-fold and 8-fold differences, respectively), and was least apparent for the quinolones, aminoglycosides, imipenem, and aztreonam (twofold differences). Selected strains for which there were high MICs of ciprofloxacin (greater than or equal to 1 micrograms/ml) were tested against ciprofloxacin in combination with other agents in a checkerboard agar dilution assay. Synergistic (summated fractional inhibitory concentration, </=0.5) interactions at clinically achievable concentrations were most frequent with mezlocillin (33%), piperacillin (21%), and (7.6%), aztreonam (3.7%), and the aminoglycosides (3.7%). Antagonism (summated fractional inhibitory concentration, >/= 4) was observed in only one instance (with gentamicin).

Sequential assessment of vaginal microflora in healthy women randomly assigned to tampon or napkin use

The effect of tampon usage on the vaginal microflora of 35 healthy women was determined following their random allocation to either tampon or napkin use for three consecutive menstrual cycles. Sequential and semiquantitative vaginal cultures were obtained on days 3 +/- 2, 15 +/- 2, and 25 +/- 2 of the menstrual cycle (day 1, first day of menses) before and after randomization. Before randomization, the rate of isolation and median counts of facultative lactobacilli were significantly higher (P less than .05) and that of eubacteria was significantly lower (P = .026) among regular tampon users than among exclusive napkin users. After randomization, only median counts of coagulase-negative staphylococci were significantly increased (P = .025) during tampon use compared with the rates for the same women during napkin use. These shifts in vaginal microflora occurred only in samples obtained during menstruation and not in those obtained at other sampling times. The data presented here support the notion that the use of tampons may result in alterations in the autochthonous vaginal microflora. It remains to be determined if these ecologic shifts in the vaginal microflora may adversely affect resistance to colonization by potential pathogens in the lower female genital tract.

Purification and purity assessment of toxic shock syndrome toxin 1

Toxic shock syndrome toxin 1 (TSST-1) was partially purified from culture supernatants by SP-Sephadex C-25 ion-exchange chromatography and subsequent Sephadex G-75 gel filtration. This protein had an apparent molecular weight of 24,000 and an isoelectric point of 7.0. The NH2-amino acid sequence for the first 40 residues agreed completely with that predicted from the known TSST-1 genome. Ouchterlony immunodiffusion with monospecific rabbit antisera demonstrated a single line of identity with reference TSST-1 as well as with three preparations obtained from other investigators. When the purity of the different TSST-1 preparations was examined by Coomassie blue or silver staining after SDS-PAGE, only the major band at molecular weight 24,000 was apparent. However, multiple additional bands were seen in all preparations when visualized either by double staining with Coomassie blue stain followed by silver stain or by immunoblot using pooled human serum. Further purification of our preparation by reverse-phase high-performance liquid chromatography eliminated some, but not all, extraneous antigens. A final purification step by preparative SDS-PAGE resulted in an eluted protein that yielded only the 24-kDa TSST-1 band and a 48-kDa dimer by immunoblot. This material was endotoxin free (sensitivity limit, 10 pg/mL) and retained biologic activity for induction of cachectin and production of interleukin 1 by human monocytes. These data emphasize the need for stringent methods of assessment of purity in TSST-1 preparations.

Serologic responses to toxic shock syndrome (TSS) toxin-1 in menstrual and nonmenstrual TSS

Toxic shock syndrome toxin-1 (TSST-1) is implicated as the major exotoxin associated with menstrual toxic shock syndrome. The role of TSST-1 in nonmenstrual TSS is less certain. We examined serum IgG responses to TSST-1 in 16 nonmenstrual (9 female, 7 male) and 14 menstrual TSS patients, and in 87 women and 66 men as age-matched healthy controls, using an enzyme-linked immunosorbent assay (ELISA). Relative ELISA titers were expressed as percent activity of a mid level serum standard tested concurrently. Based on 95% confidence estimates for predicting a negative titer (20.6 +/- 8.2%) using sera in which TSST-1 specific IgG was demonstrated to be absent by western blot, 24% of control women and 9% of control men lacked TSST-1 specific IgG in the random survey (p less than 0.05, Fisher's exact test). Relative titers in acute sera of menstrual TSS women (26.2 +/- 5.2%, mean +/- S.E.), but not nonmenstrual TSS women (71.8 +/- 18.6%), were significantly lower than those of control women (78.9 +/- 7.3%, p less than 0.01, Mann-Whitney test). Acute titers from male TSS patients (37.0 +/- 15.6%) were also significantly lower than those in control men (114.6 +/- 11.0% (p less than 0.05). Antibody titers from menstrual TSS women and TSS men remained low during convalescence. Nevertheless, seroconversion to TSST-1 was demonstrated by western blot in 7 of 10 patients in whom TSST-1 positive S. aureus was isolated, but in neither of two patients without toxigenic S. aureus.(ABSTRACT TRUNCATED AT 250 WORDS)

Synergistic interactions of ciprofloxacin and extended-spectrum beta-lactams or aminoglycosides against multiply drug-resistant Pseudomonas maltophilia

The susceptibility of 28 clinical isolates of Pseudomonas maltophilia to 16 antimicrobial agents was determined in vitro by a standard agar dilution method with inoculum sizes of 10(4) and 10(6) CFU. All isolates exhibited multiple drug resistance. Nine isolates were selected for studies of combinations of ciprofloxacin with seven antipseudomonal beta-lactams and three aminoglycosides by a checkerboard agar dilution technique. Synergistic or additive combinations of ciprofloxacin in clinically achievable concentrations were most frequent with mezlocillin (89%), followed by cefoperazone (67%), piperacillin (56%), cefsulodin (56%), and ceftazidime (33%), and were infrequent with aztreonam (11%), the aminoglycosides (0 to 14%), or imipenem (0%). Antagonism was not observed in any combination. These data suggest that combinations of ciprofloxacin with these agents may be useful for some nosocomial multiply drug-resistant P. maltophilia infections.

Synergistic interactions of ciprofloxacin and extended spectrum beta-lactams or aminoglycosides against Acinetobacter calcoaceticus ss. anitratus

The susceptibility of 54 clinical isolates of Acinetobacter calcoaceticus ss. anitratus to 16 antimicrobial agents was determined in vitro with inoculum of 10(4) and 10(6) cfu by a standard agar dilution method. The most active agents were imipenem, SCH 34343, ciprofloxacin, difloxacin (A-56619), and A-56620. Only imipenem and Abbott quinolones (A-56619 and A-56620) remained active when tested with the heavier inoculum. Except for ticarcillin and ceftazidime, which showed only moderate activity, the extended-spectrum penicillins and cephalosporins, as well as aztreonam and aminoglycosides, were inactive against these highly resistant strains. Nine isolates were selected for combination studies of ciprofloxacin with seven beta-lactams and three aminoglycosides using a checkerboard agar dilution technique. Synergistic or additive interactions at clinically achievable concentrations were more common with amikacin (eight isolates), tobramycin (seven), ceftazidime (six), cefoperazone (six), and aztreonam (six), than with other agents, including mezlocillin (four), piperacillin (three), gentamicin (two), and cefsulodin (two). Antagonism was rare, only occurring with mezlocillin in a single strain. These data suggest that combinations of ciprofloxacin with these agents may be useful for some nosocomial multidrug resistant A. calcoaceticus ss. anitratus infections.

Detection and quantitation of toxic shock syndrome toxin 1 in vitro and in vivo by noncompetitive enzyme-linked immunosorbent assay

Toxic shock syndrome toxin 1 (TSST-1), an exotoxin produced by many Staphylococcus aureus strains, is implicated as the prime causal agent of toxic shock syndrome (TSS). A sensitive and specific noncompetitive enzyme-linked immunosorbent assay (ELISA) capable of detecting TSST-1 at concentrations from 0.5 to 16 ng/ml was developed. This assay did not detect other staphylococcal enterotoxins including A, B, C1, C2, C3, D, and E. Possible interactions with protein A were readily eliminated by pretreatment of test samples with 10% normal rabbit serum. The assay was adapted for rapid screening of TSST-1 production by S. aureus isolates in culture supernatants in vitro and for detection of TSST-1 in vaginal washings of TSS patients and healthy controls in vivo. All 35 S. aureus isolates confirmed to be TSST positive by Ouchterlony immunodiffusion and 59 of 60 isolates confirmed to be TSST-1 negative gave concordant results by ELISA. Interestingly, toxigenic S. aureus strains isolated from TSS patients quantitatively produced significantly more TSST-1 in vitro compared with toxigenic control strains (P less than 0.05, Mann-Whitney rank sum test). TSST-1 could be detected by ELISA in three of four vaginal washings collected within 3 days of hospitalization from three women with acute menstrual TSS, compared with 0 of 17 washings from nine TSS patients hospitalized longer than 3 days (P = 0.003, Fisher's exact test) and 1 of 15 washings from 14 healthy control women (P = 0.016). This noncompetitive ELISA should be particularly useful for rapid screening of TSST-1 production by S. aureus isolates, for the purification and biochemical characterization of TSST-1, and for human and animal studies of the pathogenesis of TSS.

Comparison of susceptibility of gentamicin-resistant and -susceptible "Acinetobacter anitratus" to 15 alternative antibiotics

Fifty-four clinical isolates of "Acinetobacter anitratus" separated cleanly into gentamicin-susceptible (16 strains) and gentamicin-resistant (38 strains) subpopulations. When tested with a 10(4)-CFU inoculum, gentamicin resistance was associated with a greater than fourfold increase in the MICs of norfloxacin, ciprofloxacin, A-56620, tobramycin, and amikacin for 50% of the strains. Antimicrobial agents with MICs for 90% of gentamicin-resistant strains in the susceptible range were ciprofloxacin, A-56619, A-56620, imipenem, SCH-34343, ceftazidime, aztreonam, carbenicillin, ticarcillin, and piperacillin. These agents may be useful alternative drugs for treating infections caused by aminoglycoside-susceptible and -resistant "A. anitratus."

Vaginal colonization with Escherichia coli in healthy women. Determination of relative risks by quantitative culture and multivariate statistical analysis

The rate of vaginal colonization with Escherichia coli in 495 healthy women was 12% in a prospective study with use of selective media and semiquantitative culture techniques. Computer-assisted multivariate analysis revealed that vaginal E. coli was significantly associated with the menstrual phase of the cycle, prior use of antibiotics, use of diaphragm or cervical cap for contraception, history of previous urinary tract infection, and coisolation of Staphylococcus aureus that was positive for the toxic shock syndrome toxin-1 (p less than 0.05, multiple stepwise logistic regression analysis). No significant association was observed with tampon use or brand, other contraceptive methods, sexual activity, genital symptoms, recent vaginal infection, or other personal habits. Quantitative cultures obtained sequentially throughout the menstrual cycle in 12 unselected women confirmed higher E. coli counts in menstrual or midcycle samples compared to paired premenstrual specimens (p less than 0.05, Wilcoxon paired rank sign test). These data emphasize the hormonal and other host determinants in vaginal colonization by E. coli and may explain the high rate of vaginal E. coli (64%), in addition to toxicogenic S. aureus, in acute toxic shock syndrome and the higher incidence of urinary tract infection in women with diaphragm or cervical cap for contraception compared to other contraceptive methods.

In vitro susceptibility of Clostridium difficile to new beta-lactam and quinolone antibiotics

The in vitro susceptibilities of 34 to 73 clinical isolates of Clostridium difficile to 24 antimicrobial agents, including 18 beta-lactams, 4 fluoroquinolones, clindamycin, and metronidazole were examined. Metronidazole was the most active (MIC for 90% of the isolates [MIC90], 0.5 microgram/ml), followed by the carbapenems (Sch 34343, 4 micrograms/ml; imipenem, 8 micrograms/ml) and the antipseudomonas penicillins (piperacillin, 8 micrograms/ml; ticarcillin, 32 micrograms/ml; carbenicillin, 32 micrograms/ml). A monobactam (aztreonam) and most cephalosporins were either highly inactive (cefoxitin, cefuroxime, cefotiam, cefsulodin, ceftizoxime, cefbuperazone, and cefotaxime), with an MIC90 of greater than or equal to 128 micrograms/ml, or moderately inactive (ceftriaxone, cefmenoxime, cefoperazone, ceftazidime, and moxalactam), with an MIC90 of greater than or equal to 32 micrograms/ml. Clindamycin (MIC90, 32 micrograms/ml) and the fluoroquinolones (ciprofloxacin, 8 micrograms/ml; A-56619, 8 micrograms/ml; A-56620, 8 micrograms/ml; norfloxacin, 32 micrograms/ml) were only variably active. These in vitro data per se may not necessarily predict the relative risks for C. difficile-associated diarrhea or colitis during therapy with these agents. However, these data, in concert with knowledge of drug bioavailability in feces and the broad-spectrum antimicrobial activity on the resident bowel flora, may provide additional insight into the mechanisms and predictability of this complication with these agents. Careful monitoring for the emergence of C. difficile and fecal cytotoxin and for diarrhea during therapy with these agents is clearly indicated.

Vaginal colonization with Staphylococcus aureus, positive for toxic-shock marker protein, and Escherichia coli in healthy women

The vaginal colonization of 495 healthy women with strains of Staphylococcus aureus positive for the toxic-shock marker protein (pyrogenic exotoxic C) was examined prospectively. Production of the marker protein was detected by analytic isoelectrofocusing of culture filtrates in polyacrylamide gels (isoelectric point, 7.2). Toxicogenic strains of S. aureus were isolated from 2.6% of the women and nontoxicogenic strains from 4.0%. Vaginal carriage of toxicogenic S. aureus was found to be significantly correlated only with coisolation of Escherichia coli when a number of factors were analyzed by multivariate logistic regression and compared with values among women carrying no vaginal S. aureus or only nontoxicogenic strains (odds ratios, 8.17 and 11.02, respectively; 95% confidence intervals, 2.27-29.31 and 1.42-85.31, respectively). These data may explain the higher rate of vaginal colonization with E. coli in addition to toxicogenic S. aureus among women with toxic-shock syndrome (64%) than among age-matched control women (12%; P less than .001).