Violeta Temper

Changes in qnr Prevalence and Fluoroquinolone Resistance in Clinical Isolates of Klebsiella pneumoniae and Enterobacter spp. Collected from 1990 to 2005

ABSTRACT Clinical isolates of Klebsiella pneumoniae and Enterobacter spp. collected from 1990 through 2005 at a tertiary care center were studied for qnr genes. Isolates bearing these genes emerged in the mid-1990s, coinciding with the time of a rapid increase in fluoroquinolone resistance. Sixty percent of these isolates were ciprofloxacin susceptible by CLSI breakpoints.

An Outbreak of Achromobacter xylosoxidans Associated With Ultrasound Gel Used During Transrectal Ultrasound Guided Prostate Biopsy

PURPOSE We describe an outbreak of Achromobacter xylosoxidans after transrectal ultrasound guided prostate biopsy at a urology unit at a tertiary care center as well as clinical and microbiological investigation, and intervention. MATERIALS AND METHODS In September 2008, several days after undergoing transrectal ultrasound guided prostate biopsy, 4 patients were hospitalized with fever. We reviewed the procedure and infection control practices in the urology service. Environmental cultures were obtained from equipment and materials used for the procedure. Isolates were identified by routine laboratory procedures with molecular confirmation and characterized by pulsed field gel electrophoresis. RESULTS A. xylosoxidans was isolated from the urine of 2 patients, of whom 1 also had a positive blood culture. Review of transrectal ultrasound guided prostate biopsy revealed that the lubricant gel used in the procedure, which the biopsy needle passes through, was held in a plastic container that was repeatedly refilled from a large bag. A. xylosoxidans was isolated from this container. Pulsed field gel electrophoresis showed that the isolates obtained from patients and the gel were identical. CONCLUSIONS Contaminated lubricant gel was the cause of this outbreak. The practice of repeatedly refilling gel containers with nonsterile gel was replaced by the use of individual sterile gel sachets in each patient. No further cases occurred. During an invasive procedure involving a sterile body site, such as transrectal ultrasound guided prostate biopsy, using sterile gel is essential. Our experience emphasizes the crucial need to review all invasive procedures from an infection control perspective.

Panton-Valentine leukocidin-producing Staphylococcus aureus.

To the Editor: Panton-Valentine leukocidin (PVL) is a cytotoxin produced by Staphylococcus aureus that causes leukocyte destruction and tissue necrosis (1). Although produced by <5% of S. aureus strains, the toxin is detected in large percentages of isolates that cause necrotic skin lesions and severe necrotizing pneumonia (2). Although commonly associated with community-acquired methicillin-resistant S. aureus (CA-MRSA) (3), several outbreaks due to methicillin-susceptible S. aureus (MSSA) have also been reported (4–6). We describe an outbreak of cutaneous infections caused by PVL-producing MSSA that affected 6 of 11 members of 2 related families. During a period of 6 months, a cluster of S. aureus skin and soft tissue infections occurred in 2 families in Jerusalem, Israel, that were related through the mothers, who are sisters. The event started with the 4-year-old boy of family A, who had 5 episodes of skin infections, including 2 episodes of perianal abscesses that required drainage and hospitalization. Culture of pus grew MSSA that was resistant to erythromycin and clindamycin. Subsequently, recurrent abscesses and cellulitis developed in the boys fathers legs, and his mother had severe periorbital cellulitis that required hospitalization and surgical drainage. Approximately 1 month later, a 9-year-old boy in family B had severe cellulitis and abscess around his knee that required hospitalization and surgical drainage. Subsequently, infections developed in 2 more children in family B: 1 had a finger pulp-space infection and the other cellulitis of the lower abdomen. All pus cultures grew S. aureus with identical susceptibility patterns. The cases are summarized in the Table. Table Clinical and microbiologic data of the outbreak* Following these events, the families consulted the infectious diseases clinic at the Hadassah-Hebrew University Medical Center in Jerusalem. Since the clinical isolates were not available, nasal cultures were obtained from all family members. S. aureus was isolated from all the affected members of family A and from the parents and the 2 boys in family B. All 7 isolates were subjected to pulsed-field gel electrophoresis (PFGE) after digestion with SmaI. All except 1 had identical band patterns and the same antimicrobial drug susceptibilities as the clinical isolates. The presence of PVL genes was examined by PCR as previously described (2) and was detected only in the isolates with identical PFGE patterns. The families were advised to apply mupirocin nasal ointment twice a day for 5 days and to bathe with 4% chlorhexidine scrub for 1 week (7). At 7 months of follow-up, no new cases of skin infection had occurred in either family. An epidemiologic investigation was undertaken by the local department of health to determine if 3 kindergartens and 2 schools attended by the 7 children had an increased incidence of staphylococcal skin disease. No evidence of unusual disease was found. We describe here the first confirmed cases of PVL-producing S. aureus infections in Israel. Maier et al (8) recently described 2 cases of similar infections that occurred in German tourists after visiting the Dead Sea area, but since these infections were caused by MRSA, it is probable that the isolates were genetically distinct from the strain described here. In addition, to the best of our knowledge this is the first description of transmission of PVL-producing MSSA between related families. Previous reports described community-related outbreaks that occurred within families (6,8,9), between schoolmates (4), and between football team players (10). The exact route of transmission was not identified in some of these cases but it was presumed to have been close contact leading to skin (10) or nasal (4) colonization and subsequent active infection. In our report, the PVL-producing S. aureus clone was detected in nasal cultures in 6 of the 11 members of the 2 families. In this niche, it was able to persist and cause a series of infections in a relatively large number of family members. Even though the S. aureus isolated from active lesions were not available for testing, the recovery of identical PVL-positive organisms from nasal cultures strongly suggests the presence of a pathogenic clone that probably caused the recurrent infections in the 6 affected family members. Our investigation highlights the high transmissibility of this PVL-producing S. aureus clone, its high attack rate, and its virulence. The intervention in this outbreak might have prevented not only subsequent recurrences of cutaneous infections but also further spread of this clone and the manifestation of even more serious infections such as necrotizing pneumonia. Increasing awareness among community-based healthcare providers of PVL-producing S. aureus infections is important to facilitate rapid and adequate response in similar clinical events in the future.

KPC-9, a novel carbapenemase from clinical specimens in Israel.

ABSTRACT A blaKPC-9 carbapenemase variant was discovered in isolates of Klebsiella pneumoniae and Escherichia coli from a single patient. It differed from blaKPC-3 by one amino acid substitution (Val239Ala). The K. pneumoniae isolate was typed as ST258, as was the epidemic Israeli KPC-3 clone. blaKPC-9 was found on a plasmid indistinguishable from pKpQIL that carries blaKPC-3 in the epidemic clone. Compared to KPC-3, KPC-9 conferred less resistance to carbapenems and higher resistance to ceftazidime.

Cluster of pseudoinfections with Burkholderia cepacia associated with a contaminated washer-disinfector in a bronchoscopy unit.

In December 2008, bronchoalveolar lavage fluid samples obtained from 3 patients were positive for Burkholderia cepacia complex on culture. Samples obtained from bronchoscopes and rinse-water samples obtained from the washer-disinfector were found to be positive for B. cepacia complex. The cause of this pseudo-outbreak was that the washer-disinfector was installed without the required antibacterial filter.

Interactions between Scenedesmus and Microcystis may be used to clarify the role of secondary metabolites

Microcystis sp. are major players in the global intensification of toxic cyanobacterial blooms endangering the water quality of freshwater bodies. A novel green alga identified as Scenedesmus sp., designated strain huji (hereafter S. huji), was isolated from water samples containing toxic Microcystis sp. withdrawn from Lake Kinneret (Sea of Galilee), Israel, suggesting that it produces secondary metabolites that help it withstand the Microcystis toxins. Competition experiments suggested complex interaction between these two organisms and use of spent cell-free media from S. huji caused severe cell lysis in various Microcystis strains. We have isolated active metabolites from the spent S. huji medium. Application of the concentrated allelochemicals interfered with the functionality and perhaps the integrity of the Microcystis cell membrane, as indicated by the rapid effect on the photosynthetic variable fluorescence and leakage of phycobilins and ions. Although some activity was observed towards various bacteria, it did not alter growth of eukaryotic organisms such as the green alga Chlamydomonas reinhardtii.

Comparison of two carbapenem-resistant Klebsiella pneumoniae clones: from a contained outbreak in a paediatric population and from a national epidemic

OBJECTIVES A refractory epidemic of carbapenem-resistant Klebsiella pneumoniae (CRKP) emerged in the adult population at our hospital in 2005, as in most Israeli hospitals. Contemporaneously, a different clone of CRKP caused an easily contained outbreak in a paediatric long-term care facility (LTCF) in Jerusalem. While previously identified host-related risk factors for colonization by these organisms undoubtedly contributed to these outbreaks, it is very likely that bacterial factors might be crucial in explaining the striking differences in transmissibility between the implicated strains. We therefore sought bacterial factors associated with these different epidemiological behaviours. METHODS Seven CRKP isolated at our hospital and the LTCF during 2008-09 were examined by antimicrobial susceptibility testing and PFGE, and further analyses of these two clones was done using multilocus sequence typing and competition experiments. Plasmids were analysed by conjugation, restriction mapping, PCR and sequencing. RESULTS Both clones were multidrug resistant and harboured identical plasmids carrying the bla(KPC-3) gene. The hyper-transmissible epidemic clone carried additional antibiotic resistance genes and hosted an additional plasmid. The clone from the LTCF did not demonstrate hyper-transmissible properties despite its presence in an institution of a type commonly plagued by the epidemic clone. Competition assays showed the more easily contained strain to be fitter. CONCLUSIONS These findings suggest that neither the presence of the plasmid carrying the bla(KPC-3) gene nor relative survival fitness account for the hyper-transmissibility of the epidemic strain. The role of patient age in susceptibility to colonization by the epidemic strain should be investigated.

Imipenem Disc for Detection of KPC Carbapenemase-Producing Enterobacteriaceae in Clinical Practice

ABSTRACT The global spread of class A-carbapenemase-producing Enterobacteriaceae has made the development of a simple test a desirable goal. A disc diffusion test using imipenem was 100% sensitive and 96% specific in identifying carbapenemase-producing organisms, potentially reducing or eliminating the need for the relatively labor-intensive modified Hodge test.

Bordetella holmesii meningitis in an asplenic patient with systemic lupus erythematosus

Bordetella holmesii is a slow-growing, Gram-negative, non-oxidizing bacillus with colonies that produce a brown soluble pigment and was originally described by Weyant et al. (1995) as CDC nonoxidizer group 2 (NO-2). It has recently been shown that B. holmesii may be isolated from nasopharyngeal specimens of up to 20% of patients with pertussis-like symptoms. However, invasive B. holmesii has rarely been reported and in the vast majority of cases the patients were immune deficient, mostly as a result of splenectomy or functional asplenia. Clinical presentations have included endocarditis, pneumonia, cellulitis, suppurative arthritis, pyelonephritis and septicaemia but no previous reports have documented meningitis secondary to this organism. Here we report what we believe to be the first clinical description of an adult with B. holmesii meningitis and bacteraemia with a brief review of published cases.

Imported Melioidosis, Israel, 2008

In 2008, melioidosis was diagnosed in an agricultural worker from Thailand in the southern Jordan Valley in Israel. He had newly diagnosed diabetes mellitus, fever, multiple abscesses, and osteomyelitis. Burkholderia pseudomallei was isolated from urine and blood. Four of 10 laboratory staff members exposed to the organism received chemoprophylaxis, 3 of whom had adverse events.