Elizabeth T. S. Houang

Incidence and risk factors for microbial keratitis in Hong Kong: comparison with Europe and North America.

Purpose To establish the incidence, etiology and risk factors for microbial keratitis (MK) in Hong Kong.Methods Two hundred and twenty-three new cases of presumed MK were recruited over a period of 17 months and comprehensive microbiologic studies performed. A nested case-control study was pursued for patients wearing contact lenses (CLW) to determine risk factors for MK with regards to types of CLW and hygiene practice.Results Of the 223 patients recruited, 59 (26%) wore contact lenses. Corneal scrapes yielded positive cultures from 77 patients (35% overall, 56 non-CLW, 21 CLW). Two hundred and six CLW volunteers were recruited to participate in the case-control study, of whom 135 were matched with 45 CLW patients. The annual incidence of MK was 0.63 per 10 000 population and 3.4 per 10 000 CLW with rates for daily, extended and rigid lens wear of 3.09, 9.30 and 0.44 per 10 000 CLW respectively. Pseudomonas aeruginosa was the dominant bacterial pathogen. Six cases of Acanthamoeba keratitis occurred, five in CLW (incidence 0.33 per 10 000 CLW) and one following corneal abrasion. Non-CLW developed MK at a peak age of 73, which is 10 years younger than expected for Scotland and USA.Conclusions Previous ocular surface disease and trauma were the main risk factors for MK in Hong Kong. CLW appears at least as safe as that found in Scotland and the USA. Acanthamoeba keratitis was detected but with an incidence rate five times lower than Scotland. Factors predisposing hydrogel CLWs to MK, that were statistically significant, included overnight wear, poor hygiene and smoking.

IMP-4, a Novel Metallo-β-Lactamase from Nosocomial Acinetobacter spp. Collected in Hong Kong between 1994 and 1998

ABSTRACT Between 1994 and 1998, 97 imipenem-resistantAcinetobacter isolates were identified at the Prince of Wales Hospital, Hong Kong, China. A blaIMP PCR product was obtained from 23 of 35 viable cultures; 12 isolates belonged to genomic DNA group 3, 8 belonged to group 2 (Acinetobacter baumannii), 2 belonged to group 13TU, and 1 belonged to group 1. The blaIMP homologues were sequenced from two isolates from genomic DNA group 2 and one isolate each from groups 3 and 13TU. The four sequences included an identical 738-bp open reading frame, predicted to encode a polypeptide of 246 amino acids, with 95.6% homology to IMP-1 and 89.3% homology to IMP-2. The new enzyme, designated IMP-4, was partially purified. It had a pI of 8.0 and was strongly active against imipenem and meropenem, with Vmax values 53 and 8% of that for penicillin G, respectively. Strong activity was also seen against oxyimino-aminothiazolyl cephalosporins but not against aztreonam. Hydrolytic activity was inhibited by EDTA but not by clavulanate or tazobactam. Carbapenem MICs for mostblaIMP-positive isolates were 4 to 32 μg/ml, but one isolate with the intact gene was susceptible, with imipenem and meropenem MICs of 0.25 and 0.5 μg/ml, respectively. The latter isolate did not produce the band with a pI of 8.0, and gene expression was inferred to have been lost. None of the isolates studied in detail contained extrachromosomal DNA, and carbapenem resistance was not transmissible to Escherichia coli. Nevertheless, the presence of blaIMP-4 in different genomic DNA groups implies horizontal transfer, and sequences resembling a GTTRRRY integrase-dependent recombination motif were identified in the flanking regions of blaIMP-4.

Microbial keratitis in Hong Kong: relationship to climate, environment and contact-lens disinfection

Microbial keratitis has been studied in Hong Kong as a representative sub-tropical climate of south China. An 18-month investigation in 1997/98 of 223 cases of ulcerative keratitis (presumed microbial) was conducted in the 2 million population of Shatin and Kowloon at the Prince of Wales and Hong Kong Eye Hospitals respectively with comprehensive microbiology. A case-control study was pursued at the same time between 45 contact-lens wearers (CLW) developing microbial keratitis and 135 lens-wearing volunteers matched for age, sex, educational status and visual acuity. Home water supplies were sampled for Acanthamoeba. Previous ocular surface disease and trauma (preventable by wearing goggles for grinding) were common predisposing causes while cosmetic wear of contact lenses was responsible for 26% of cases overall. Pseudomonas aeruginosa was the commonest bacterium isolated, from both CLW and non-CLW, with infection being acquired within the community. These 28 pseudomonads remained fully sensitive to the third-generation cephalosporins, aminoglycosides and quinolone antibiotics, which is very encouraging. Fungi were isolated, predominantly Fusarium sp., but less commonly than expected. A fungal/bacterial ratio was obtained of 1/17, while in comparison, the expected ratio for a tropical climate ranges from 1/5 (Singapore) to 1/2 (South India). Acanthamoeba was the second commonest microbe isolated from keratitis of CLW. The domestic water environment of 8% of homes of both patients and controls wearing contact lenses was colonized with Acanthamoeba. Lack of hygiene, use of tap water for storing lenses, failure to air-dry lens-storage cases or use of one-step hydrogen peroxide disinfectant were identified as risk factors for keratitis in CLW. The study results commend use of multipurpose solutions by CLW in Hong Kong to achieve the lowest expected rates of infection.

Epidemiology of Rifampin ADP-Ribosyltransferase (arr-2) and Metallo-β-Lactamase (blaIMP-4) Gene Cassettes in Class 1 Integrons in Acinetobacter Strains Isolated from Blood Cultures in 1997 to 2000

ABSTRACT We characterized two new gene cassettes in an Acinetobacter isolate: one harbored the metallo-β-lactamase (IMP-4) gene blaIMP-4, the other harbored the rifampin ADP-ribosyltransferase (ARR-2) gene arr-2, and both arrayed with the aminoglycoside acetyltransferase [AAC(6′)-Ib7] gene cassette aacA4 in two separate class 1 integrons. The epidemiology of these gene cassettes in isolates from blood cultures obtained from 1997 to 2000 was studied. Isolates bearing either the blaIMP-4 or the arr-2 gene cassette or both represented 17.5% (10 of 57) of isolates in 1997, 16.1% (10 of 62) in 1998, 2.5% (1 of 40) in 1999, and 0% (0 of 58) in 2000. These two gene cassettes, probably borne on two separate integrons, were found in at least three genomic DNA groups, with evidence of clonal dissemination in the intensive care unit during 1997 to 1998. Seventeen of the 52 Acinetobacter baumannii (genomic DNA group 2) isolates from 1997 to 2000 harbored intI1, but only one was positive for these gene cassettes, whereas 20 of the 21 intI1-positive isolates of all other genomic DNA groups were positive for either or both of them. Reduced susceptibility to imipenem and rifampin was seen only in isolates harboring the blaIMP-4 and arr-2 cassettes, respectively. The aminoglycoside phosphotransferase [APH(3′)-VIa] gene aph(3′)-VIa was detected in all 21 isolates for which the MIC of amikacin was ≥8 μg/ml, with or without aacA4, whereas aacA4 alone was found in isolates for which the MIC of amikacin was 0.5 to 2 μg/ml. Significant differences between the 17 intI1-positive and 47 intI1-negative isolates belonging to genomic DNA group 3 from 1997 to 1998 in the MICs of amikacin, gentamicin, imipenem, sulfamethoxazole, and ceftazidime were observed (Mann-Whitney test, P < 0.001 to 0.01).

Novel Resistance-Nodulation-Cell Division Efflux System AdeDE in Acinetobacter Genomic DNA Group 3

ABSTRACT Resistance-nodulation-cell division type efflux pump AdeDE was identified in acinetobacters belonging to genomic DNA group 3. Inactivation of adeE showed that it may be responsible for reduced susceptibility to amikacin, ceftazidime, chloramphenicol, ciprofloxacin, erythromycin, ethidium bromide, meropenem, rifampin, and tetracycline. However, unlike what was found for other similar efflux systems, the open reading frame for the outer membrane component was not found downstream of the adeDE gene cluster.

Significance of Genomic DNA Group Delineation in Comparative Studies of Antimicrobial Susceptibility of Acinetobacter spp.

ABSTRACT There were significant differences in antimicrobial susceptibilities in isolates of genomic DNA groups 2 (Acinetobacter baumannii), 3, and 13TU collected from the same sources, e.g., patients in intensive care units and general wards, and in isolates of the same group collected from different sources. The delineation of genomic groups is important in comparative surveillance studies of antimicrobial susceptibilities.

The use of CHROMagar Orientation as a primary isolation medium with presumptive identification for the routine screening of urine specimens

The aim of the study was to compare the use of a novel differential culture medium CHROMagar, for both primary isolation and presumptive identificaton, with the method currently used in our laboratory for screening mid‐stream‐urine samples (MSU). Routine methods (RM) included blotting paper imprinting of all specimens and additional quantitative culture on cysteine lactose electrolyte‐deficient agar (CLED) for selected samples together with Microbact 12E for further identification. The CHROMagar method (CH) relied on the use of blotting paper imprints, colonial colour and morphology on CHROMagar only. With respect to the 3390 MSU specimens examined, both methods yielded similar results in 3240, including ≤87% of Escherichia coli, Pseudomonas spp., Staphylococcus spp., Proteus mirabilis/ Morganella morganii and Enterobacter/Serratia/Klebsiella/Citrobacter spp. Of the 52 discordant identifications, yeasts were reported as staphylococci on CHROMagar in 10. The overall cost of materials per specimen was US

Acanthamoeba keratitis and contact lens wear

0.30 by RM and

Polyhexamethylene biguanide (0.02%) alone is not adequate for treating chronic Acanthameoba keratitis.

0.24 by CH. It took about 3 min to perform each Microbact test. Thus, CHROMagar plus Gram stain and other simple bench tests gave results similar to those using our current method, but had the advantage of saving time and materials.

Skin Carriage of Acinetobacters in Hong Kong

Vol 350 • November 15, 1997 1481 of domestic water in the high-rise buildings typical of Hong Kong often comes from a tank located on the building’s roof, suggesting that the risk factor of domestic water may also be important in Hong Kong. Reports suggest that acanthamoeba keratitis is an emerging disease in south and east Asia where there has been an increase in the use of contact lenses. With substantial cultural, social, environmental, and climatic differences between Asia and elsewhere, we believe studies to determine risk factors for this disorder are a matter of urgency.