Completeness of reporting of rabies postexposure prophylaxis in King County, Washington.

The completeness of rabies postexposure prophylaxis (PEP) reporting was evaluated in King County, Washington State. Information on rabies immune globulin prescriptions was obtained from hospital pharmacies associated with emergency departments in King County from 2003 to June 2006. Rabies immune globulin is given at the initiation of rabies PEP which is usually started at emergency departments. Because pharmacies are not regular sources of rabies PEP reporting, we compared pharmacy cases with cases reported via routine passive surveillance methods. A capture-recapture method was used to calculate the estimated number of unreported cases from all sources. Reporting completeness was calculated by dividing the number of cases reported via routine surveillance with the sum of reported and estimated unreported cases. Seventy-one unreported rabies PEP cases were identified by comparing previously reported cases with pharmacy cases. A total of 128 cases were estimated to have been missed by the surveillance system. Overall reporting completeness was 62 percent increasing to almost 80 percent in 2005 and 2006. Our findings illustrate the importance of evaluating surveillance systems and suggest that it may be useful to institute active rabies PEP surveillance with emergency departments in addition to continuing educating healthcare providers and facilities about reporting.

The presence of a conjugative Gram-positive Tn2009 in Gram-negative commensal bacteria.

OBJECTIVES: To determine whether mef(A)-msr(D) and tet(M) genes are linked in representative Gram-negative isolates and/or transferred together during conjugation. To molecularly characterize the Acinetobacter junii element and compare the structure and sequence with the non-conjugative Streptococcus pneumoniae Tn2009 element. METHODS: PCR assays, DNA-DNA hybridization and sequencing of PCR products were used. Nucleotide sequences were determined at the integration site of the mef(A) element into Tn916 and upstream and downstream flanking regions of the element. RESULTS: A total of 10 mef(A)-msr(D)- and tet(M)-positive isolates carried conjugative element(s). The A. junii Tn2009 element was indistinguishable from S. pneumoniae Tn2009. The region upstream of the A. junii Tn2009 contained an orf that was 89-91% identical to an S. pneumoniae spr1206 gene found upstream of the streptococcal Tn2009. In the A. junii, the spr1206 gene was separated by 67 bp from the end of the Tn2009, while 29 bp were found separating spr1206 from the streptococcal Tn2009. The 1201 bp downstream A. junii sequences included 913 unique sequences. CONCLUSIONS: A total of 10 different Gram-negative genera were found to carry the tet(M) genes, including the first description in three genera (Citrobacter, Proteus and Stenotrophomonas). All isolates were able to transfer the genes into > or =1 recipient with macrolide selection. Over 3000 bp were sequenced on each side of the insertion mef junction region in the A. junii and were indistinguishable from the streptococcal Tn2009. The A. junii Tn2009 element was flanked by an S. pneumoniae gene upstream and a unique sequence downstream, suggesting that the A. junii Tn2009 could be part of a larger element.

Staphylococcus efflux msr(A) gene characterized in Streptococcus, Enterococcus, Corynebacterium, and Pseudomonas isolates.

The staphylococcal msr(A) gene, coding for a macrolide efflux protein, was identified in three new gram-positive genera and one gram-negative genus. These msr(A) genes shared 99 to 100% identity with each other and the staphylococcal gene. This study demonstrates that the msr(A) gene has a wider host range than previously reported.