Advances in the bacteriology of the coliform group: their suitability as markers of microbial water safety.

Advances in the elaboration of novel genomic types of beta-galactosidase-positive Enterobacteriaceae and comprehensive studies of their habitats have resulted in an innovative approach to the assessment of the merits and shortcomings of the thermotrophic and fecal species Escherichia coli and all other coliforms as markers of the microbiological safety of water. As one of the consequences, it is recommended to abolish the "technical" designation fecal coliforms because their current method of detection will result in the isolation of thermotrophic organisms that have been demonstrated, beyond a doubt, to be of environmental, rather than uniquely enteric origin. Additional population studies have demonstrated that none of the coliforms can function as reliable markers for all enteric pathogens (index organisms sensu Ingram), nor be of use in validating adequate processing for safety of raw water, which represents the indicator function of markers, as defined by Ingram. Future studies along these lines will have to provide the data required to assess the suitability of additional markers for the reliable monitoring of drinking water for microbiological safety.

Method for studying development of colonization and infection of dialysis catheters.

Microbial colonization and infection of dialysis catheters is the major cause of catheter failure. The present study aimed to develop a method to permit the study of microbial biofilm formation and antibiotic prophylaxis and therapy. Standard silicon rubber and silver-impregnated catheters were sectioned into 1 mm slices and placed into 1-cm x 2-cm culture slide chambers. Fresh clinical isolates were obtained from infected patients and suspended in concentrations of 10(3), 10(6), and 10(9) colony forming units (CFU) per milliliter in a variety of liquid suspending culture media, which included serum protein constituents. Antibiotics could be added to the suspending fluid to determine prophylactic activity, or at any time thereafter to determine therapeutic activity. The catheter sections were incubated with the microbial challenge for 6 hours, 12 hours, 24 hours, and 48 hours and then washed in flowing distilled water to remove unattached biofilm. They were then stained with acridine orange, which fluoresces microbial DNA, and were examined by confocal scanning laser microscopy. Biofilm formation, representing colonization and infection, were quantified by comparing the fluorescent pixel analysis of the uninoculated control with the challenged catheter. The method was reproducible and permitted quantitative analysis. Standard silicon rubber catheters demonstrated greater biofilm formation than silver-impregnated catheters. The method examines the factors involved in microbial colonization and infection, and in antibiotic prophylaxis and therapy.

Endocarditis caused by culture-negative organisms visible by Brown and Brenn staining: utility of PCR and DNA sequencing for diagnosis.

Two cases of culture-negative endocarditis with cocci seen in valve vegetations are presented. The organisms were identified by molecular analysis using broad-range PCR primers complementary to the 16S rRNA gene, sequencing, and database search using BLAST software. The results and utility of this method are discussed.

Escherichia coli: the best biological drinking water indicator for public health protection.

Public health protection requires an indicator of fecal pollution. It is not necessary to analyse drinking water for all pathogens. Escherichia coli is found in all mammal faeces at concentrations of 10 log 9(-1), but it does not multiply appreciably in the environment. In the 1890s, it was chosen as the biological indicator of water treatment safety. Because of method deficiencies, E. coli surrogates such as the 'fecal coliform' and total coliforms tests were developed and became part of drinking water regulations. With the advent of the Defined Substrate Technology in the late 1980s, it became possible to analyse drinking water directly for E. coli (and, simultaneously, total coliforms) inexpensively and simply. Accordingly, E. coli was re-inserted in the drinking water regulations. E. coli survives in drinking water for between 4 and 12 weeks, depending on environmental conditions (temperature, microflora, etc.). Bacteria and viruses are approximately equally oxidant-sensitive, but parasites are less so. Under the conditions in distribution systems, E. coli will be much more long-lived. Therefore, under most circumstances it is possible to design a monitoring program that permits public health protection at a modest cost. Drinking water regulations currently require infrequent monitoring which may not adequately detect intermittent contamination events; however, it is cost-effective to markedly increase testing with E. coli to better protect the public's health. Comparison with other practical candidate fecal indicators shows that E. coli is far superior overall.

Microsporidia and Cyclospora: epidemiology and assessment of risk from the environment.

Two classes of parasites with an environmental stage in their lifestyle have recently emerged as significant gastrointestinal pathogens for humans. Microsporidia represent a group that contains a number of genera related to the genus Cryptosporidium. They are generally transmitted via direct human to human contact, but can survive in water and food, and recently have been found in surface water used as drinking source water. Their most common host range is in patients with clinical AIDS. Limited work to date suggests the group is susceptible to chlorine achievable CxT (concentration x time) values and is coagulated by filtration. Cyclospora cayetanensis is a species of parasite that has caused outbreaks from contaminated food. Its major risk is from the use of inadequately treated water used for irrigation. Cyclospora can infect normal and immunosuppressed hosts. Current information regarding the lifestyle, transmission, and control of both groups of parasites are discussed, with a health risk assessment analysis.

Bacteriophages as indicators of enteric viruses and public health risk in groundwaters.

Low concentrations of all types of bacteriophages in groundwater limit their power to predict the presence of enteric viruses. There is little concordance in the literature regarding phage detection methods, thus making comparisons extremely difficult. Different authors have used different hosts, phage concentration methods, and end-point determinations. Also, markedly different volumes of sample have been employed, varying from 1 litre to 400 l. Bacteriophage concentration methods are not reproducible. There has been marked variability among groups in the natural substrates used (for example, beef extract), the type of adsorbing filter used, centrifugation instruments and conditions, and the delivery of the concentrate to the host cells. There is no consensus on the best bacterial host strain. Currently, several are employed with each showing differential sensitivities and specificities. In particular, host stability must be considered. Host stability has two components: the ability of the host to continue to be receptive to the bacteriophage after continued sub-culture, and the lack of lysogenic or temperate bacteriophage in the host cell line which may be randomly and unpredictably activated. There is a lack of consistent recovery of bacteriophages from individual faecal specimens. In particular, only approximately 3% of individual humans carry the FRNA phages. While there is some evidence to indicate that the phages multiply in sewage, it is not clear how they do so since the host pili should not be produced at lower temperatures. These ecological factors need to be understood. Of all the phages thus far studied, Bacteroides fragilis HSP40 has the highest recovery rate from individual people. However, Bacteroides, being an anaerobe, is a difficult host for routine laboratory analysis. Methods for the enumeration of F(+)-specific phages and Bacteroides phages are complex, time-consuming, costly and not reproducible. Conversely, somatic coliphage methods are simpler and results can be available in 4-6 h. The occurrence of phages and viruses in groundwater depends on physicochemical characteristics that control their fate and transport in the groundwater/aquifer environment. There are very little actual data taken from the field that allow an understanding of the ecology and life span of phages in their natural environment. Moreover, the ability of phages to serve as a source of food for other microbes needs to be understood. There has been a lack of association of bacteriophage recovery with gastroenteritis outbreaks due to enteric viruses. There is only a small epidemiological database concerning the occurrence of enteric viruses in groundwater.

Management of a Sabiá virus-infected patients in a US hospital.

OBJECTIVE: To describe the hospital precautions used to isolate a Sabiá virus (arenavirus: Arenaviridae)-infected patient in a US hospital and to protect hospital staff and visitors. DESIGN: Investigation of a single case of arenavirus laboratory-acquired infection and associated case-contacts. SETTING: A 900-bed, tertiary-care, university-affiliated medical center. PATIENTS OR OTHER PARTICIPANTS: The case-patient became ill with Sabiá virus infection. The case-contacts consisted of healthcare workers, coworkers, friends, and relatives of the case-patient. INTERVENTION: Enhanced isolation precautions for treatment of a viral hemorrhagic fever (VHF) patient were implemented in the clinical laboratory and patient-care setting to prevent nosocomial transmission. The enhanced precautions included preventing aerosol spread of the virus from the patient or his clinical specimens. All case-contacts were tested for Sabiá virus antibodies and monitored for signs and symptoms of early disease. RESULTS: No cases of secondary infection occurred among 142 case-contacts. CONCLUSIONS: With the frequency of worldwide travel, patients with VHF can be admitted to a local hospital at any time in the United States. The use of enhanced isolation precautions for VHF appeared to be effective in preventing secondary cases by limiting the number of contacts and promoting proper handling of laboratory specimens. Patients with VHF can be managed safely in a local hospital setting, provided that appropriate precautions are planned and implemented.

Analysis of cytotoxicity and invasiveness of heterotrophic plate count bacteria (HPC) isolated from drinking water on blood media.

Heterotrophic plate count (HPC) bacteria are naturally present in all aqueous environments. These bacteria undergo multiplication cycles in drinking water, especially in closed containers (bottled water) or in tap water when chlorine levels are dissipated, such as in dead ends in water mains or household plumbing. A study was undertaken to estimate health risk from these naturally occurring bacteria by the determination of cytotoxicity and invasiveness in a human enterocyte cell line. HPC bacteria were isolated from bottled and tap water samples by enumerating them under physical and chemical conditions analogous to human physiology. All HPC bacteria were examined at both log and lag phase of their growth cycles. Bacterial broth supernatant fluids were also tested to serve as critical negative controls. Naturally occurring HPC bacteria demonstrated low invasiveness and cytotoxicity with more than 95% of isolates showing equivalency to broth supernatant fluid. When showing either invasiveness or cytotoxicity, only a small number of cells from the culture were positive. Of those that were positive, log phase HPC bacteria were significantly more cytotoxic and invasive than those from stationary phase. Bacterial broth controls demonstrated varied, but often marked, cytotoxicity.

Natural protection of spring and well drinking water against surface microbial contamination. I. Hydrogeological parameters.

The fate and transport of microbes in groundwater are controlled by physicochemical characteristics of the microbe and of the groundwater/aquifer media. Key characteristics of the microbe include size, inactivation (die-off) rate, and surface electrostatic properties. Key properties of the groundwater/aquifer system include flow velocity, aquifer grain (or pore) size, porosity, solid organic carbon content, temperature, pH, and other chemical characteristics of water and mineral composition. Because of size and surface electrical properties, viruses are much more mobile in groundwater than Cryptosporidium and Giardia (which are about 100 times or more larger than viruses). The inactivation or die-off rate is usually the most important factor governing how far microbes can migrate in significant numbers in groundwater. Typical half-lives of microbes in groundwater range from a few hours to a few weeks. Examples of maximum reported migration distances of microbes in groundwater include: bacteria, 600 m in a sandy aquifer: viruses, 1000 to 1600 m in channeled limestones and 250 to 408 m in glacial silt-sand aquifers; Cryptosporidium and Giardia, no confirmed reports found of significant migration distances. Investigations by the EPA have indicated that distances of 210 to 325 m away from septic tanks are necessary to achieve with high confidence an 11 order of magnitude reduction in virus concentrations.

Natural protection of spring and well drinking water against surface microbial contamination. II. Indicators and monitoring parameters for parasites.

Recent outbreaks of cryptosporidiosis and reports of other newly described para-sitic diseases associated with drinking water transmission prompted a reevaluation of source water monitoring criteria for public health protection. The field of microbial indicators was reviewed and each candidate sentinel evaluated in terms of its sensitivity, specificity, and technical feasibility. In addition, a clear distinction was made between source water monitoring and monitoring in the distribution system. Of all potential candidate microbial sentinels, Escherichia coli is deemed the most efficacious for public health protection. Based on a conservative estimate of its half-life in groundwater for 8 d, it is recommended that at least two samples be obtained during this half-life. In addition to E. coli, two water quality indicator sentinels, which are not necessarily direct public health threats, should also be monitored at the same frequency. These are the total coliform group and the enterococci. If E. coli is present in any source water sample, the borehole and any directly connected borehole should be embargoed. If either total coliforms or enterococci are detected, only that individual borehole should be taken off line and not used until the situation is remediated and the cause of the fecal contamination eliminated. Clostridium perfringens spores serve as a useful long-lived indicator. However, their perseverance in a sample should not be considered a direct public health threat because spores may far outlive pathogens. As a parasite indicator, C. perfringens should have the same importance as a positive coliform or enterococcus analysis. Coliphages do not yet fulfill enough of the criteria to be routinely employed. Biological monitoring should be coupled with physicochemical monitoring to establish a long-term history of the source. Because all natural waters vary in the amounts of heterotrophic plate count bacteria, test methods should be employed that are refractory to them. A combination of rigorous source protection plus extraordinary source monitoring serve as sufficient multiple barriers for parasite protection.

Pseudomonas aeruginosa: assessment of risk from drinking water.

Pseudomonas aeruginosa is an ubiquitous environmental bacterium. It can be recovered, often in high numbers, in common food, especially vegetables. Moreover, it can be recovered in low numbers in drinking water. A small percentage of clones of P. aeruginosa possesses the required number of virulence factors to cause infection. However, P. aeruginosa will not proliferate on normal tissue but requires previously organs. Further narrowing the risk to human health is that only certain specific hosts are at risk, including patients with profound neutropenia, cystic fibrosis, severe burns, and those subject to foreign device installation. Other than these very well-defined groups, the general population is refractory to infection with P. aeruginosa. Because of its ubiquitous nature, it is not only not practical to eliminate P. aeruginosa from our food and drinking water, but attempts to do so would produce disinfection byproducts more hazardous than the species itself. Moreover, because there is no readily available sensitive and specific means to detect and identify P. aeruginosa available in the field, any potential regulation governing its control would not have a defined laboratory test measure of outcome. Accordingly, attempts to regulate P. aeruginosa in drinking water would not yield public health protection benefits and could, in fact, be counterproductive in this regard.

Host-microbe interaction in the gastrointestinal tract.

In order for an infection to occur, the target organ must come in contact with sufficient microbes, the microbe must possess specific virulence factors, these virulence factors must be expressed, and the defenses of the organ system must be overcome. This dynamic process, which is ongoing in all living entities, can be described by the following relationship: [formula: see text] The establishment of infection first occurs in a particular organ. This phenomenon is known as tissue trophism and the association of microbes with organ systems governs the practice of clinical microbiology and infectious disease. With some microbes (e.g., Giardia, Cryptosporidium) the interaction with the particular organ is so specific that infections are almost always confined to one site; with others (e.g., Salmonella, enterovirus) the microbe has the potential to become systemic. When attempting to establish health risk assessment from microbes by contact with food and drinking water, one must therefore consider that the gastrointestinal tract is a complex organ system with a variety of specific host defense mechanisms. It is only when the microbe has particular virulence factors for sites in gastrointestinal tract, and the specific host defense mechanisms in the gastrointestinal tract are breached, that infection of this organ system occurs. Therefore, the general terms "immunosuppression" or "immunocompromise" are meaningless unless the specific immune defect is known. A description of the microbial virulence factors active against the gastrointestinal tract and the defense mechanisms of this organ system are reviewed to provide a biological basis health risk assessment and future food and drinking water regulations.

Effects of white cell reduction on the resistance of blood components to bacterial multiplication.

BACKGROUND: While prestorage white cell (WBC) reduction by filtration may improve platelet and red cell quality, it also may remove an important anti-bacterial defense mechanism, especially if blood is WBC-reduced shortly after collection. STUDY DESIGN AND METHODS: The question of whether WBC reduction of platelet concentrates and red cells altered bacterial proliferation kinetics in components prepared from deliberately contaminated, freshly collected blood was investigated. Two-unit pools of whole blood were inoculated, at a concentration of approximately one colony-forming unit per mL, with one of 17 bacterial species reported to have caused septicemia in transfusion recipients. Each pool was divided after inoculation, and components were prepared from the 2 units after a 7-hour room-temperature holding period. One unit of each AS-1 red cell or platelet pair was WBC-reduced, and the pairs were then stored for 42 days at 4 degrees C (red cells) or for 10 days at 22 degrees C (platelets). Quantitative bacterial cultures were performed at periodic intervals. RESULTS: In red cells, clinically significant bacterial proliferation occurred in only one instance (Serratia marcescens), and growth was less rapid in the WBC-reduced unit than in the control. Three patterns of growth were seen in platelet concentrates. In four cases, there was rapid proliferation in both test and control units, while on 13 occasions there was minimal replication in either pair. On six occasions, substantial growth was noted in control units, while few or no bacteria could be found in the WBC-reduced units. There was no evidence in either red cells or platelets that bacteria proliferated more rapidly in units that had been WBC-reduced before storage than they did in units in which WBCs were retained. CONCLUSION: Rather than increasing the risk of bacterial proliferation through removal of active phagocytic cells, WBC reduction by filtration before blood storage may act to reduce the likelihood of significant bacterial proliferation, possibly by removal of microorganisms along with WBCs.

Rapid detection of vancomycin-resistant enterococci.

Campylobacter blood agar with clindamycin incubated in 6% CO2 served as a medium to both screen for vancomycin resistance and select for presumptive enterococci. Colonies that grew on the medium were specifically identified as enterococci within 30 min by the pyroglutamyl-beta-naphthylamide and rapid bile esculin tests. The combination of a selective medium plus rapid enzyme substrate tests offered an inexpensive means to enumerate vancomycin-resistant enterococci from specimens by using readily available reagents.

Differentiation of distribution systems, source water, and clinical coliforms by DNA analysis.

During a 2-week period, Enterobacter cloacae was isolated from throughout the water distribution system in New Haven County, Connecticut. There was no forewarning of this event and no apparent reasons for it. Several epidemiologic and public health questions required rapid answers. Were these E. cloacae isolates the result of treatment failure and breakthrough or was regrowth occurring within the system? Did the E. cloacae isolates represent a health threat and were they causing infection? Pulsed-field gel electrophoresis utilizing whole-cell DNA digestion with restriction endonuclease SpeI permitted the rapid generation of specific information to answer these questions. Gel bands were stained with ethidium bromide and photographed with UV illumination. Homogeneity among isolates was confirmed by repeat digestion with XbaI. From each of the water distribution isolates, a single pattern of restriction endonuclease fragments was generated, indicating that only one clone of E. cloacae was in the distribution system. There was no homogeneity between source and distribution water E. cloacae isolates. Moreover, E. cloacae clinical isolates from patients from New Haven area hospitals showed no identity with E. cloacae isolated from the distribution system. Therefore, pulsed-field gel electrophoresis DNA analysis demonstrated that the E. cloacae from the distribution system was the result of a regrowth bloom within the system and not the result of treatment failure and that this clone was not causing a public health risk.

Cryptococcal antigen detection from the urine of AIDS patients.

Cryptococcal disease occurs in < or = 10% of AIDS patients. Detection of the capsular polysaccharide antigen of the yeast in spinal fluid or serum is used to establish the diagnosis. In addition, cryptococcal antigen (CAg) analysis is used to adjust treatment and evaluate recurrence of active disease. A specimen such as urine, obtained noninvasively, would be optimum for this evaluation. Urine, cerebrospinal fluid (CSF), and serum for CAg analysis, and culture of urine and CSF, were obtained for 103 sets of specimens from 92 patients. CSF and urine specimens for CAg were analyzed with and without pronase treatment; serum was analyzed with pronase only. Twenty percent (21 of 103) of specimen sets showed CAg from eight patients. In all cases, patients with positive CSF and/or serum titers also had positive urine titers. Titers were always serum > CSF > urine, with ranges of 1: 64-65000; 1: 64-6250; and 1: 2-512, respectively. Pronase treatment did not affect CSF titers, but 14 of 23 titers from urine treated with pronase were at least one dilution higher than those without treatment. No false-positive reactions were observed during the study. CSF cultures were positive from seven of eight, and urine cultures were positive from five of eight patients with CAg. These results indicate that urine can be used as a specimen for detection of CAg in AIDS patients and that use of pronase may increase its sensitivity.

Detection and identification of Mycobacterium directly from BACTEC bottles by using a DNA-rRNA probe.

Detection and identification of mycobacterial species using DNA-rRNA probes from colonies has been used for some time. Guidelines for probe use with a specific minimum growth index (GI) cutoff from BACTEC 12B bottles or its use with 7H9 broth has not been defined. This study defined this minimum GI guideline. Clinical specimens received during the study period were decontaminated and directly inoculated into BACTEC 12B bottles and appropriate solid media. An initial probe test was performed at a GI reading of > or = 100. An additional probe test was made at GI of > or = 300. A total of 1377 specimens were processed with 98 specimens containing 99 isolates of Mycobacterium. Of these, 82 were M. avium complex (MAC), six were M. tuberculosis (Mtb), and 11 were other species. At a GI of > or = 100, 82% of MAC were detected; at a GI of > or = 300, 89% were detected. All Mtb were detected at a GI of > or = 100. The probes correctly identified all isolates from backup 7H9 broths. There were no false-positive probe results for any of the isolates from either BACTEC 12B or 7H9 media. Therefore, the DNA-rRNA probe test at a GI of > or = 300 saves considerable time (on average, 21 days saved) for the detection and identification of Mtb and MAC. This time saving compares with waiting for the production of colonies while retaining acceptable sensitivity and excellent specificity.

Evaluation of the Gen-Probe PACE II assay for the direct detection of Neisseria gonorrhoeae in endocervical specimens.

Evaluation of a non-isotopic DNA-rRNA hybridization assay [Probe Assay-Chemiluminescence Enhanced System (PACE II, Gen-Probe, San Diego, CA)] for the direct detection of Neisseria gonorrhoeae from clinical specimens was compared with culture. Culture and probe tests were performed on 795 endocervical specimens. Results demonstrated that total positives by culture were 18 (2.3% of total); both culture and the DNA-rRNA assay agreed in all cases but four. The PACE II yielded four hybridization-positive results with negative companion cultures. The sensitivity, specificity, and positive and negative predictive values for PACE II were 100%, 99.5%, and 82%, and 100%, respectively. The four discrepant results were resolved using a competitive nucleic acid hybridization assay with recalculated sensitivity, specificity, and positive and negative predictive values of 100, 99.7, and 91.6 and 100%, respectively. Overall, the DNA-rRNA assay offered a number of advantages over culture. The assay was more rapid, able to be performed directly on clinical specimens, and provided superior transport stability.