Kevin C. Hazen

New and emerging yeast pathogens.

The most common yeast species that act as agents of human disease are Candida albicans, Candida tropicalis, Candida glabrata, Candida parapsilosis, and Cryptococcus neoformans. The incidence of infections by other yeasts has increased during the past decade. The most evident emerging pathogens are Malassezia furfur, Trichosporon beigelii, Rhodotorula species, Hansenula anomala, Candida lusitaniae, and Candida krusei. Organisms once considered environmental contaminants or only industrially important, such as Candida utilis and Candida lipolytica, have now been implicated as agents of fungemia, onychomycosis, and systemic disease. The unusual yeasts primarily infect immunocompromised patients, newborns, and the elderly. The role of central venous catheter removal and antifungal therapy in patient management is controversial. The antibiograms of the unusual yeasts range from resistant to the most recent azoles and amphotericin B to highly susceptible to all antifungal agents. Current routine methods for yeast identification may be insufficient to identify the unusual yeasts within 2 days after isolation. The recognition of unusual yeasts as agents of sometimes life-threatening infection and their unpredictable antifungal susceptibilities increase the burden on the clinical mycology laboratory to pursue complete species identification and MIC determinations. Given the current and evolving medical practices for management of seriously ill patients, further evaluations of the clinically important data about these yeasts are needed.

Chronic Sinusitis: Relationship of Computed Tomographic Findings to Allergy, Asthma, and Eosinophilia

OBJECTIVE To develop a technique for evaluating the severity of chronic sinus disease and to examine the correlation with allergy, asthma, and eosinophilia. DESIGN A survey of 104 patients undergoing surgery for chronic sinusitis. SETTING A university hospital ear, nose, and throat clinic. PATIENTS A referral population of adult patients being scheduled for endoscopic sinus surgery was eligible; 104 completed questionnaires and agreed to participate. MAIN OUTCOME MEASURES Computed tomographic scans were reviewed and scored for extent of disease. Serum samples were assayed for total IgE and specific IgE antibodies to common inhalant allergens. Peripheral blood samples were analyzed for total eosinophil count. Surgical biopsy specimens were examined for eosinophilia and cultured for bacteria and fungi. RESULTS Extensive disease was present in 39% of subjects and correlated well with asthma, specific IgE antibodies, and eosinophilia, but not with elevated total IgE. Among patients with peripheral eosinophilia, 87% had extensive disease. All cultures grew aerobic bacteria; anaerobes and fungi were uncommon. CONCLUSIONS We present a system for quantitation of disease extent using computed tomographic scans of patients with chronic sinusitis. The well-accepted associations of chronic sinusitis with asthma and allergy appear to be restricted to the group with extensive disease. The presence of peripheral eosinophilia in patients with sinusitis indicates a high likelihood of extensive disease.

Molecular Dissection of an Outbreak of Carbapenem-Resistant Enterobacteriaceae Reveals Intergenus KPC Carbapenemase Transmission through a Promiscuous Plasmid

ABSTRACT Carbapenem-resistant Enterobacteriaceae (CRE) have emerged as major causes of health care-associated infections worldwide. This diverse collection of organisms with various resistance mechanisms is associated with increased lengths of hospitalization, costs of care, morbidity, and mortality. The global spread of CRE has largely been attributed to dissemination of a dominant strain of Klebsiella pneumoniae producing a serine β-lactamase, termed K. pneumoniae carbapenemase (KPC). Here we report an outbreak of KPC-producing CRE infections in which the degree of horizontal transmission between strains and species of a promiscuous plasmid is unprecedented. Sixteen isolates, comprising 11 unique strains, 6 species, and 4 genera of bacteria, were obtained from 14 patients over the first 8 months of the outbreak. Of the 11 unique strains, 9 harbored the same highly promiscuous plasmid carrying the KPC gene blaKPC. The remaining strains harbored distinct blaKPC plasmids, one of which was carried in a strain of Klebsiella oxytoca coisolated from the index patient and the other generated from transposition of the blaKPC element Tn4401. All isolates could be genetically traced to the index patient. Molecular epidemiological investigation of the outbreak was aided by the adaptation of nested arbitrary PCR (ARB-PCR) for rapid plasmid identification. This detailed molecular genetic analysis, combined with traditional epidemiological investigation, provides insights into the highly fluid dynamics of drug resistance transmission during the outbreak. IMPORTANCE The ease of horizontal transmission of carbapenemase resistance plasmids across strains, species, and genera of bacteria observed in this study has several important public health and epidemiological implications. First, it has the potential to promote dissemination of carbapenem resistance to new populations of Enterobacteriaceae, including organisms of low virulence, leading to the establishment of reservoirs of carbapenem resistance genes in patients and/or the environment and of high virulence, raising the specter of untreatable community-associated infections. Second, recognition of plasmid-mediated outbreaks, such as those described here, is problematic because analysis of resistance plasmids from clinical isolates is laborious and technically challenging. Adaptation of nested arbitrary PCR (ARB-PCR) to investigate the plasmid outbreak facilitated our investigation, and the method may be broadly applicable to other outbreaks due to other conserved mobile genetic elements. Whether infection control measures that focus on preventing transmission of drug-resistant clones are effective in controlling dissemination of these elements is unknown. The ease of horizontal transmission of carbapenemase resistance plasmids across strains, species, and genera of bacteria observed in this study has several important public health and epidemiological implications. First, it has the potential to promote dissemination of carbapenem resistance to new populations of Enterobacteriaceae, including organisms of low virulence, leading to the establishment of reservoirs of carbapenem resistance genes in patients and/or the environment and of high virulence, raising the specter of untreatable community-associated infections. Second, recognition of plasmid-mediated outbreaks, such as those described here, is problematic because analysis of resistance plasmids from clinical isolates is laborious and technically challenging. Adaptation of nested arbitrary PCR (ARB-PCR) to investigate the plasmid outbreak facilitated our investigation, and the method may be broadly applicable to other outbreaks due to other conserved mobile genetic elements. Whether infection control measures that focus on preventing transmission of drug-resistant clones are effective in controlling dissemination of these elements is unknown.

A polystyrene microsphere assay for detecting surface hydrophobicity variations within Candida albicans populations

Abstract Adherence of microbial pathogens to host cell surfaces may involve hydrophobic interactions. Here, we describe the development of an assay for detecting cell surface hydrophobicity of populations and individual cells of the opportunistic fungal pathogen Candida albicans . The assay involves mixing polystyrene latex microspheres with cells and subsequent enumeration of cell-attached microspheres. Similar levels of hydrophobicity within a population of yeast cells were obtained with the microsphere assay and with a commonly used aqueous-hydrocarbon biphasic partitioning assay. Various buffers were found to support detection of surface hydrophobicity with the microsphere assay. Complex fungal growth media did not. Serum in test media prevented microsphere attachment. A unique advantage of the assay compared to others is that individual cells can be assessed for surface hydrophobicity. Within a population of C. albicans yeast cells, strongly, moderately and weakly hydrophobic cells were observed. Within some pairs of mother-daughter cells, only one cell was hydrophobic. Germ tbes and hyphae were hydrophobic regardless of the hydrophobic status of the parent cell. These results indicate that the microsphere assay is a useful test evaluating cell surface hydrophobicity of C. albicans .

Cell wall protein mannosylation determines Candida albicans cell surface hydrophobicity

Cell surface hydrophobicity (CSH) has been shown to be an important factor in the ability of the opportunistic pathogenic yeast Candida albicans to adhere to surfaces. Hydrophobic cells adhere more readily to host tissue, and are more resistant to phagocytic killing, than hydrophilic cells. Consequently, CSH plays an important role in the pathogenicity of C. albicans. Previous work suggested a relationship between CSH and cell wall protein glycosylation. The present work tests the hypothesis that changes in outer chain mannosylation, rather than complete loss of oligosaccharide groups, are sufficient to modulate CSH. These studies compared wild-type cells to a variant that has altered mannosylation and is hydrophobic under conditions in which wild-type cells are hydrophilic. Composition analysis of cell surface digests showed that the glycosylation of wild-type cell surface proteins was much more extensive than that seen in the variant. Antibodies which recognize the acid-labile and acid-stable portions of C. albicans mannan showed not only differences between wild-type and variant cells but also differences between wild-type hydrophilic and wild-type hydrophobic cells. The results suggest that exposure of surface hydrophobic regions on C. albicans may be related to the abundance of phosphodiester-linked, acid-labile mannosyl groups rather than the complete loss of outer chain mannosylation on cell wall proteins.

Comparison of the Susceptibilities of Candida spp. to Fluconazole and Voriconazole in a 4-Year Global Evaluation Using Disk Diffusion

ABSTRACT From June 1997 to December 2001, results of in vitro susceptibility tests of yeast isolates from 35 countries were collected. For 2001 alone, fluconazole results were reported for 22,111 yeast isolates from 77 institutions in 30 countries. Of these isolates, 18,569 were also tested for susceptibility to voriconazole. All study sites tested clinical yeast isolates by recently endorsed NCCLS disk diffusion method M44-P. Disk test plates were automatically read and results were recorded with the BIOMIC Image Analysis System. Species, drug, zone diameter, susceptibility category, MIC, and quality control results were electronically submitted by e-mail quarterly for analysis. Duplicate test results (same patient and same species with same sensitivity-resistance profile and biotype results during any 7-day period) and uncontrolled test results were eliminated from this analysis. The proportion of Candida albicans isolates decreased from 69.7% in 1997 to 1998 to 63.0% in 2001, and this decrease was accompanied by a concomitant increase in C. tropicalis and C. parapsilosis. The susceptibility (susceptible [S]or susceptible-dose dependent [S-DD]) of C. albicans isolates to fluconazole was virtually unchanged, from 99.2% in 1997 to 99% in 2001; the C. glabrata response to fluconazole was unchanged, from 81.5% S or S-DD in 1997 to 81.7% in 2001, although the percentage of resistant isolates from blood and upper respiratory tract samples appeared to increase over the study period; the percentage of S C. parapsilosis isolates decreased slightly, from 98% S or S-DD in 1997 to 96% in 2001; and the percentage of S isolates of C. tropicalis increased slightly, from 95.7% in 1997 to 96.9% in 2001. The highest rate of resistance to fluconazole among C. albicans isolates was noted in Ecuador (7.6%, n = 250). Results from this investigation indicate that the susceptibility of yeast isolates to fluconazole has changed minimally worldwide over the 4.5-year study period and that voriconazole demonstrated 10- to 100-fold greater in vitro activity than fluconazole against most yeast species.

Optimal Susceptibility Testing Conditions for Detection of Azole Resistance in Aspergillus spp.: NCCLS Collaborative Evaluation

ABSTRACT The most important role of susceptibility testing is to identify potentially resistant isolates for the agent being evaluated. Standard testing guidelines recently have been proposed for antifungal susceptibility testing of filamentous fungi (molds). This collaborative (eight centers) study evaluated further newly proposed guidelines (NCCLS, proposed standard M38-P, 1998) and other testing conditions for antifungal susceptibility testing of Aspergillus spp. to itraconazole and three new triazoles, posaconazole (SCH56592), ravuconazole (BMS-207147), and voriconazole. MICs of itraconazole, posaconazole, ravuconazole, and voriconazole for 15 selected isolates of three species of Aspergillus (A. fumigatus, A. flavus, and A. terreus) with well documented in vitro, clinical, or animal data were determined in each center by using four medium formulations (standard RPMI-1640 [RPMI], RPMI with 2% dextrose, antibiotic medium 3 [M3], and M3 with 2% dextrose) and two criteria of MIC determination (complete [MIC-0s] and prominent [MIC-2s] growth inhibition) at 24, 48, and 72 h. The highest reproducibility (92 to 99%) was seen with the standard RPMI and M3 media. Moreover, the distinction between itraconazole-resistant (MICs of >8 μg/ml for clinically resistant strains) and -susceptible (MICs of 0.03 to 1 μg/ml) isolates, as well as between a voriconazole-resistant laboratory mutant and other isolates (voriconazole MICs of 2 to >8 versus 0.12 to 2 μg/ml), was more consistently evident with the standard RPMI medium and when MIC-0s were determined at 48 h. These results provide further refinement of the testing guidelines for susceptibility testing ofAspergillus spp. and warrant consideration for inclusion in the future NCCLS document M38-A.

First Clinical Cases of OXA-48-Producing Carbapenem-Resistant Klebsiella pneumoniae in the United States: the “Menace” Arrives in the New World

ABSTRACT OXA-48 has emerged as a major carbapenemase associated with the Enterobacteriaceae in Europe, North Africa, and Asia. We report the first two clinical cases of OXA-48-type carbapenemase-producing Enterobacteriaceae in the United States from patients recently hospitalized in Saudi Arabia and India. Each is more carbapenem resistant than nearly all previously reported OXA-48-type-producing Enterobacteriaceae.

Fatal cross infection by carbapenem-resistant Klebsiella in two liver transplant recipients

Abstract: Members of the family Enterobacteriaceae including Klebsiella have re‐emerged as major pathogens in solid organ transplantation. The recent appearance and dissemination of carbapenemase‐producing Enterobacteriaceae in Europe and the northeastern United States represents a major challenge to the treatment of enteric gram‐negative bacterial infections in immunocompromised patients; however, few reports have detailed the outcomes of such infections. Here we report 2 cases of Klebsiella pneumoniae carbapenemase (KPC)‐producing Klebsiella infections in orthotopic liver transplant recipients, which were the index case and initial secondary case for an outbreak of KPC‐producing Enterobacteriaceae in our institution. In both instances, the pathogens were initially misidentified as being carbapenem sensitive, the infections recurred after cessation of directed therapy, and the patients ultimately succumbed to their infections.

Cloning and Analysis of a Candida albicans Gene That Affects Cell Surface Hydrophobicity

The opportunistic pathogenic yeast Candida albicans exhibits growth phase-dependent changes in cell surface hydrophobicity, which has been correlated with adhesion to host tissues. Cell wall proteins that might contribute to the cell surface hydrophobicity phenotype were released by limited glucanase digestion. These proteins were initially characterized by their rates of retention during hydrophobic interaction chromatography--high-performance liquid chromatography and used as immunogens for monoclonal antibody production. The present work describes the cloning and functional analysis of a C. albicans gene encoding a 38-kDa protein recognized by the monoclonal antibody 6C5-H4CA. The 6C5-H4CA antigen was resolved by two-dimensional electrophoresis, and a partial protein sequence was determined by mass spectrometry analysis of tryptic fragments. The obtained peptides were used to identify the gene sequence from the unannotated C. albicans DNA database. The antibody epitope was provisionally mapped by peptide display panning, and a peptide sequence matching the epitope was identified in the gene sequence. The gene sequence encodes a novel open reading frame (ORF) of unknown function that is highly similar to several other C. albicans ORFs and to a single Saccharomyces cerevisiae ORF. Knockout of the gene resulted in a decrease in measurable cell surface hydrophobicity and in adhesion of C. albicans to fibronectin. The results suggest that the 38-kDa protein is a hydrophobic surface protein that meditates binding to host target proteins.