Ralstonia spp. in a dialysis unit: an experience in the identification and control of an outbreak / Ralstonia spp. en una unidad de diálisis: experiencia en la identificación y control de brote

Abstract Objective: to describe an experience in identification and control of an outbreak of Ralstonia spp. in a renal unit. Material and Method: an epidemiological investigation of a hospital outbreak in 2 sites and extramural service of a renal unit. The investigation included patients who presented fever or chills, during or after dialysis, and who had positive blood culture for Ralstonia spp. Results: Of 769 hemodialysis patients, 124 were identified with bacteremia by Ralstonia spp.; of these, 98.4% had catheter access and 1.6% had fistula. The overall attack rate was 16.1% and the case fatality rate was 0.8%. Environmental cultures were taken and drugs and devices were tracked. Several cultures were taken of the prefilled heparin following the methods described in the International Pharmacopoeia. However, it was the technique of microbial isolation recommended by experts that enabled the isolation of the microorganism and confirmed the source. Conclusions: The outbreak described exceeded the number of patients affected documented in literature. It was caused by a contaminated batch of heparin. Evidence is provided of a recommended by expert technique used for the isolation of Ralstonia spp. in order to achieve control of outbreaks in a timely manner, minimizing clinical, economic, and social impact.

Resumen Objetivo: describir la experiencia en la identificación y control de un brote por Ralstonia spp. en una unidad renal. Material y Método: investigación epidemiológica de brote hospitalario en 2 sedes y servicio extramural de una unidad renal. Se incluyeron pacientes que presentaron fiebre o escalofrío, durante o después de la terapia dialítica, y que tuvieran hemocultivo positivo para Ralstonia spp. Resultados: De los 709 pacientes para hemodiálisis, se identificaron 124 con bacteriemia por Ralstonia spp., 98,4% tenían acceso por catéter. La tasa de ataque global fue del 16,1% y la tasa de letalidad 0,8%. Se realizaron cultivos ambientales y trazabilidad de medicamentos y dispositivos, pero ante la presencia de casos extramurales la hipótesis fue redireccionada. La heparina prellenada había sido cultivada en varias oportunidades siguiendo la metodología de la farmacopea internacional. Sin embargo, la técnica de aislamiento microbiano recomendada por expertos fue la que permitió aislar el microorganismo y confirmar la fuente. Conclusiones: El brote que se describe excedió el número de pacientes documentados en la literatura y fue causado por un lote contaminado de heparina. Se aporta evidencia de una técnica recomendada por expertos utilizada para el aislamiento de Ralstonia spp. a fin de lograr el control de brotes de manera oportuna, minimizando el impacto clínico, económico y social.

Evaluation of resistance to natural poisoning by Amorimia septentrionalis in goats which had received sodium monofluoroacetate degrading bacteria / Avaliação da resistência à intoxicação natural por Amorimia septentrionalis em caprinos que receberam bactérias degradadoras de monofluoroacetato de sódio

Amorimia septentrionalis is an important sodium monofluoroacetate (MFA) containing plant that causes sudden death in ruminants in northeastern Brazil. MFA degrading bacteria are being used in the prevention against poisoning by this plant. The aim of this study was to evaluate if goats which had per os received MFA degrading bacteria remained resistant when exposed to natural poisoning by A. septentrionalis. Eighteen goats were randomly distributed into three groups: the goats of Group 1 previously received, during 40 days, a solution containing the bacteria Ralstonia sp. and Burkholderia sp., those goats in the Group 2 received the bacteria Paenibacillus sp. and Cupriavidus sp. and goats from Group 3 did not receive any bacteria. After the administration period, during 60 days, the animals of all groups were released to graze on a one hectare paddock, with significant amount of A. septentrionalis. They were observed daily for the spontaneous consumption of A. septentrionalis leaves and the occurrence of clinical signs of poisoning or sudden death. Goats from all groups consumed significant amounts of A. septentrionalis during the experimental period. Goats that did not receive MFA-degrading bacteria (Group 3) became sick and died from the 25th to the 27th day of the experiment, whereas the goats of the groups that received MFA-degrading bacteria showed only clinical sings when A. septentrionalis regrowth after the 55th day of the experiment. The days elapsed from field observation to death of Group 3 goats (25.5±0.9 days) were significantly lower (p<0.05) than Group 1 (58.6±1.3 days) and Group 2 (57.8±1.5 days). Thus, it can be concluded that administration of MFA degrading bacteria increases the resistance to natural poisoning by A. septentrionalis.(AU)

Amorimia septentrionalis que contém monofluoroacetato de sódio (MFA) é responsável pela ocorrência de mortes súbitas em ruminantes no nordeste do Brasil. Bactérias degradadoras desse composto estão sendo utilizadas na prevenção contra a intoxicação por essa planta. O objetivo deste estudo foi avaliar se caprinos que receberam, via oral, bactérias degradadoras de MFA permaneciam resistentes quando expostos a intoxicação natural por A. septentrionalis. Dezoito caprinos foram divididos em três grupos, os caprinos do Grupo 1 receberam anteriormente, durante 40 dias, uma solução contendo as bactérias Ralstonia sp. e Burkholderia sp., os do Grupo 2 receberam, também por 40 dias as bactérias Paenibacillus sp. e Cupriavidus sp. e os do Grupo 3 não receberam nenhuma bactéria. Após o período de administração, durante 60 dias, os animais de todos os grupos foram soltos para pastar em um piquete de um hectare, que apresentava uma quantidade significativa da planta. Diariamente eles foram observados quanto ao consumo espontâneo das folhas de A. septentrionalis e quanto à presença de sinais clínicos de intoxicação ou morte. Os caprinos de todos os grupos consumiram quantidades significantes da planta durante o período experimental. Os caprinos que não receberam as bactérias degradantes de MFA (Grupo 3) adoeceram e morreram entre o 25º e o 27º dia de experimento, enquanto que os que receberam as bactérias degradantes de MFA (Grupo 1 e 2) só apresentaram sinais clínicos no 55º dia de experimento, o que coincidiu com a rebrota da planta. Os dias transcorridos desde a observação a campo até a morte dos caprinos do Grupo 3 (25,5±0,9 dias) foram significativamente menores (p<0,05) que os do Grupo 1 (58,6±1,3 dias) e do Grupo 2 (57,8±1,5 dias). Com isso pode-se concluir que a administração de bactérias degradadoras de MFA aumenta à resistência a intoxicação natural por A. septentrionalis.(AU)

Ralstonia mannitolilytica bacteremia in a neonatal intensive care unit

Abstract Ralstonia mannitolilytica, a Gram-negative bacterium, is rarely isolated in clinical laboratories. It has been associated with outbreaks due to its ability to survive in liquid media and hospital devices. We describe three cases of bacteremia caused by R. mannitolilytica in a neonatal intensive care unit in Curitiba, Southern Brazil. All isolates presented the same PFGE profile. The common source of infection was undetected in surveillance cultures for the outbreak survey. All patients received antimicrobial treatment and were discharged from the maternity. Due to the characteristics of the microorganism, clinicians and microbiologists should pay attention to the emergence of Ralstonia spp. infections.

Brote de Ralstonia mannitolilytica a partir de bacteriemias asociadas a catéteres implantables y semiimplantables en un hospital pediátrico / Outbreak of Raistonia mannitolilytica by implantable and semi-implantable catheter-related bacteremia in a pediatric hospital

Ralstonia mannitolilytica junto con Ralstonia pickettii han sido asociadas con brotes hospitalarios relacionados con la contaminación de algún dispositivo o fluido. El objetivo de este trabajo fue describir un brote por R. mannitolilytica a partir de bacteriemias asociadas a catéteres implantables y semiimplantables ocurrido en un hospital pediátrico de alta complejidad y evaluar la utilidad del empleo de métodos moleculares para su investigación.Se detectó la presencia de bacilos gram negativos no fermentadores, con igual antibiotipo, en hemocultivos y retrocultivos a partir de dos pacientes que tenían catéteres implantables y estaban atendidos en una misma área del hospital. Se realizaron estudios microbiológicos de muestras de frascos de heparina, soluciones de dextrosa y soluciones antisépticas con resultado negativo. Algunos pacientes tuvieron signos y/o síntomas clínicos de bacteriemia al habilitar los catéteres para su uso. Se citaron para su estudio a todos los pacientes que habían tenido un procedimiento de apertura y cierre de catéter durante las fechas cercanas a los hallazgos en hemocultivos (N expuestos = 45). Ocurrieron 17 casos (infectados), a partir de los cuales se analizaron 23 aislamientos, en los que se pudo documentar la presencia de R. mannitolilytica (23 aislamientos). Por métodos moleculares se determinó que los aislamientos provenientes de muestras de pacientes involucrados en el brote se encontraban estrechamente relacionados y podrían representar una misma cepa o clon. Por evidencia circunstancial se consideró a la "solución heparínica de cierre" como fuente posible del brote (AU)

Both Ralstonia mannitolilytica and Ralstonia pickettii have been associated with hospital outbreaks due to device or fluid contamination. The aim of this study was to describe an implantable- or semi-implantable-catheter-related bacteremia outbreak by R. mannitolilytica in a tertiary-care hospital and to assess the usefulness of molecular analysis for the identification of the organism. Non-fermenting gram-negative bacilli, with identical antibiotypes, were detected in hemocultures of two patients with implantable catheters in the same hospital area. Microbiological studies of heparin and dextrose and antiseptic solution vials were negative. Some of the patients had clinical signs and/or symptoms of bacteremia when the catheter was prepared for use. All patients who underwent a procedure of accessing or locking the port of the catheter around the time of the positive hemoculture findings were contacted (N exposed = 45). Seventeen infections were detected, of which 23 isolates were analyzed. The presence of R. mannitolilytica was recorded in 23 isolates. Molecular analysis showed that the isolates from the samples of the patients involved in the outbreak were closely related and might represent the same strain or clone. Circumstantial evidence suggested that the heparin-lock solution may have been the source of the outbreak (AU)

A Fosmid Cloning Strategy for Detecting the Widest Possible Spectrum of Microbes from the International Space Station Drinking Water System

In this study, fosmid cloning strategies were used to assess the microbial populations in water from the International Space Station (ISS) drinking water system (henceforth referred to as Prebiocide and Tank A water samples). The goals of this study were: to compare the sensitivity of the fosmid cloning strategy with that of traditional culture-based and 16S rRNA-based approaches and to detect the widest possible spectrum of microbial populations during the water purification process. Initially, microbes could not be cultivated, and conventional PCR failed to amplify 16S rDNA fragments from these low biomass samples. Therefore, randomly primed rolling-circle amplification was used to amplify any DNA that might be present in the samples, followed by size selection by using pulsed-field gel electrophoresis. The amplified high-molecular-weight DNA from both samples was cloned into fosmid vectors. Several hundred clones were randomly selected for sequencing, followed by Blastn/Blastx searches. Sequences encoding specific genes from Burkholderia, a species abundant in the soil and groundwater, were found in both samples. Bradyrhizobium and Mesorhizobium, which belong to rhizobia, a large community of nitrogen fixers often found in association with plant roots, were present in the Prebiocide samples. Ralstonia, which is prevalent in soils with a high heavy metal content, was detected in the Tank A samples. The detection of many unidentified sequences suggests the presence of potentially novel microbial fingerprints. The bacterial diversity detected in this pilot study using a fosmid vector approach was higher than that detected by conventional 16S rRNA gene sequencing.

Investigation on the Hemodialysis System Contaminated with Ralstonia Pickettii / 병원감염관리

INTRODUCTION: To prevent hemodialysis-related infections, it is important to maintain hemodialysis system without microbial contamination. In May 2003, routine surveillance showed that dialysis water from dialysis port was contaminated with bacteria. To identify the causes of the contamination, we conducted an investigation as follows. METHODS: Patients undergoing dialysis were carefully monitored to see whether evidences of pyrogenic reactions or infections were present. Factors that could have influence on bacterial contamination in hemodialysis systems were thoroughly examined. In addition, microbiologic surveillances were done 7 times in 1 month. RESULTS: Although pyrogenic reactions or bacteremia did not occur, R. pickettii was repeatedly isolated above the Association for the Advancement of Medical Instrumentation (AAMI) standards from almost all dialysis units. Bacterial counts of specimens were higher in the proximal part of the water supply tube than the other parts in all dialysis machines. The colony count of R. pickettii exceeded the maximum level of technical limit in the specimens collected from the dialysis machines in the early morning after intermission of 48 hours. The structure of the supply tube was suspected as the origin of the colonization because stagnant water is a reservoir for bacterial multiplication. After remodeling the structure of the water supply tube, neither R. pickettii nor any other bacteria were isolated. CONCLUSION: Our investigation successfully identified the source of R. pickettii contamination of reverse osmosis water. Appropriate corrective measures for water distribution systems of hemodialysis center could prevent outbreak of dialysis-associated illnesses.

A Case of Corneal Ulcer Caused by Ralstonia Paucula Infection

PURPOSE: There has not been any reports of Ralstonia paucula causing any ophthalmologic disease. However, we have detected Ralstonia paucula in the lens washing agents of a corneal ulcer patient wearing contact lens. METHODS: A 26-years-old female patient was admitted to our hospital complaining of loss of visual acuity and hyperemia. Slit lamp biomicroscopy and smear culture was done to the anterior segment of the eye and the lens cleansing agent. The patient was treated with antibiotic eye drop and intravenous antibiotic medication. RESULTS: The results of both smear and culture showed the presence of Ralstonia pacula and responded well to antibiotics treatment with ceftazidime.