Point of Care Echocardiography in an Irish Critical Care Unit

Aims We sought to evaluate the clinical impact of a 6 month transthoracic echocardiography (TTE) teaching programme in a critical care unit. Methods An observational single centre study. Four critical care doctors, 2 fellows and 2 consultants were trained to use TTE. The study was conducted over 2 six month study periods; period 1 before echocardiography training and period 2 following echocardiography training. Results An increased number of TTE examinations were performed following echocardiography training, 47 TTE studies during period 1 and 144 TTE studies during period 2. The commonest indications for TTE examination were assessment of ventricular function, wall motion abnormalities and cardiac tamponade. The percentage of TTE studies leading to a change in clinical management were similar during both periods, 30% period 1 and 34% period 2. During period 2 the majority of TTE's leading to management change were performed by critical care doctors who frequently manipulated vasoactive medications and administered fluid therapy. Conclusions A 6 month echocardiography training programme led to an increase number of TTE studies independently performed by critical care doctors with resultant clinical impact in one third of cases.

The characterization of Listeria spp. isolated from food products and the food-processing environment.

AIM: To enhance the information pertaining to the epidemiology of a collection of 378 Listeria spp. isolates obtained from several food-processing plants in Ireland over a 3-year period (2004-2007). METHODS AND RESULTS: The collection was characterized by pulsed-field gel electrophoresis (PFGE). The most prevalent pulse-type was PFGE profile I (n=14·5%) that consisted mainly of environmental Listeria spp. samples. Serotyping of 145 Listeria monocytogenes isolates was performed. The most common serovar was 1/2a and comprised 57·4% (n=77) of the L. monocytogenes collection. The other serovars were as follows: 4b (14·1%, n=19), 1/2b (9·7%, n=13), 4c (4·4%, n=6) and 1/2c (6·7%, n=9), respectively. Eleven isolates were identified as non-Listeria spp., the remaining ten L. monocytogenes isolates were nontypeable. The antimicrobial susceptibility testing revealed the antibiotic that isolates displayed the most resistance to was gentamicin (5%) followed by sulfamethoxazole-trimethoprim (2%), tetracycline and ciprofloxacin (1·5%). CONCLUSIONS: The subtyping has indicated the diversity of the Listeria spp. The presence of serotype 1/2a, 1/2b and 4b in both raw and cooked ready-to-eat food products is a public health concern, as these serotypes are frequently associated with foodborne outbreaks and sporadic cases of human listeriosis. In addition, the emergence of antimicrobial-resistant L. monocytogenes isolates could have serious therapeutic consequences. SIGNIFICANCE AND IMPACT OF STUDY: The molecular subtyping and the further characterization of these isolates may be valuable particularly in the context of a suspected common source outbreak in the future.

Transfer of ampicillin resistance from Salmonella Typhimurium DT104 to Escherichia coli K12 in food.

AIMS: To investigate the transfer of antibiotic resistance from a donor Salmonella Typhimurium DT104 strain to a recipient Escherichia coli K12 strain. METHODS AND RESULTS: Mating experiments were conducted in broth, milk and ground meat (beef) at incubation temperatures of 4, 15, 25 and 37 degrees C for 18 and 36 h. Ampicillin-resistance transfer was observed at similar frequencies in all transfer media at 25 and 37 degrees C (10(-4) to 10(-5) log(10 )CFU ml g(-1), transconjugants per recipient) for 18 h. At 15 degrees C, transfer was observed in ground meat in the recipient strain (10(-6), log10 CFU g(-1), transconjugants per recipient), but not in broth or milk. At 4 degrees C, transfer did not occur in any of the examined mediums. Further analysis of the E. coli K12 nal transconjugant strain revealed the presence of a newly acquired plasmid (21 kbp) bearing the beta-lactamase gene bla(TEM). Transconjugants isolated on the basis of resistance to ampicillin did not acquire any other resistant markers. CONCLUSION: This study demonstrates the transfer of antibiotic resistance in food matrices at mid-range temperatures. SIGNIFICANCE AND IMPACT OF THE STUDY: It highlights the involvement of food matrices in the dissemination of antibiotic-resistant genes and the evolution of antibiotic-resistant bacteria.

Isolation and characterisation of toxin A-negative, toxin B-positive Clostridium difficile in Dublin, Ireland.

Clostridium difficile is a major cause of infectious diarrhoea in hospitalised patients. Most pathogenic C. difficile strains produce two toxins, A and B; however, clinically relevant toxin A-negative, toxin B-positive (A- B+) strains of C. difficile that cause diarrhoea and colitis in humans have been isolated worldwide. The aims of this study were to isolate and characterise A- B+ strains from two university hospitals in Dublin, Ireland. Samples positive for C. difficile were identified daily by review of ELISA results and were cultured on selective media. Following culture, toxin-specific immunoassays, IMR-90 cytotoxicity assays and PCR were used to analyse consecutive C. difficile isolates from 93 patients. Using a toxin A-specific ELISA, 52 samples produced detectable toxin. All isolates were positive using a toxin A/B ELISA. Similarly, all isolates were positive with the cytoxicity assay, although variant cytopathic effects were observed in 41 cases. PCR amplification of the toxin A and toxin B genes revealed that 41 of the previous A- B+ strains had a c. 1.7-kb deletion in the 3'-end of the tcdA gene. Restriction enzyme analysis of these amplicons revealed the loss of polymorphic restriction sites. These 41 A- B+ isolates were designated toxinotype VIII by comparison with C. difficile strain 1470. PCR ribotyping revealed that all A- B+ isolates belonged to PCR-ribotype 017. A- B+ C. difficile isolates accounted for 44% of the isolates examined in this study, and appeared to be isolated more frequently in Dublin, Ireland, than reported rates for other countries.

Antimicrobial resistance in Irish isolates of verocytotoxigenic Escherichia coli (E. coli)--VTEC.

This study compared the antimicrobial resistance profiles of Escherichia coli O157:H7 isolates (n=257) recovered from bovine hides, minced beef and human clinical samples in Ireland, to those profiles of a range of Irish non-O157 E. coli (O111 and O26) isolates (n=31) from a variety of clinical and veterinary sources. Four multi-drug resistant (MDR) E. coli O157:H7 food isolates were identified, with resistance to 10 (1 isolate), 6 (1 isolate) and 4 (2 isolates) antimicrobial agents, respectively. Two of these isolates (resistant to 7 and 4 antimicrobial classes) were characterised further by molecular methods and found to contain class 1 integrons along with a beta-lactamase-encoding tem-1 gene. Transfer of antimicrobial resistance (ampicillin, streptomycin and sulphonamides), the tem-1 gene and markers (int1, qacEDelta1, sul1) characteristic of class 1 integrons were evident in one MDR isolate (resistant to 4 antimicrobial classes) when conjugation and transformation experiments were performed. A clinical isolate and a veterinary isolate of the O111 serotype were MDR and resistant to 4 and 3 antimicrobial classes, respectively. These data suggest that the prevalence of antimicrobial resistance among the three VTEC serotypes examined in this study is low. However, these organisms may become a public health risk should they enter the food chain.

Methicillin-resistant Staphylococcus aureus isolated from a veterinary surgeon and five dogs in one practice.

Methicillin-resistant Staphylococcus aureus (MRSA) was isolated from five dogs with wound discharges after surgical procedures at a veterinary practice, and MRSA with similar molecular and phenotypic characteristics was isolated from the nares of one veterinary surgeon in the practice. The pulsed-field gel electrophoresis patterns of all the isolates were indistinguishable from each other and from the most common human isolates of MRSA in Ireland.

Methicillin-resistant Staphylococcus aureus (MRSA) isolated from animals and veterinary personnel in Ireland.

Reports of methicillin-resistant Staphylococcus aureus (MRSA) in animals have become more frequent in recent years. This paper documents the recovery of MRSA from animals with respiratory, urinary tract or wound infection and from animals subjected to surgical procedures following treatment in one veterinary hospital and 16 private veterinary clinics in different geographical locations throughout Ireland. MRSA was recovered from 25 animals comprising 14 dogs, eight horses, one cat, one rabbit and a seal, and also from 10 attendant veterinary personnel. Clinical susceptibility testing suggested that the 35 isolates fell into two different groups. One group of isolates (Group 1) was resistant to one or more of the following classes of antimicrobials: macrolides, lincosamines, tetracyclines and/or fluoroquinolones. The second group (Group 2) was resistant to macrolides, aminoglycosides, tetracyclines and trimethoprim/sulphamethoxazole and variably resistant to fluoroquinolones, lincosamines and rifampicin. One isolate in Group 2 was susceptible to trimethoprim. Epidemiological typing by antibiogram-resistogram (AR) typing, biotyping and by chromosomal DNA restriction fragment length polymorphism analysis using SmaI digestion followed by pulsed field gel electrophoresis (PFGE), confirmed these two major clusters. PFGE analysis showed that most isolates from non-equine animals were indistinguishable from each other and from the isolates from personnel caring for these animals. MRSA was isolated from eight horses which attended six different veterinary practices before referral to an equine veterinary hospital. Isolates from the eight horses and from their attendant personnel had PFGE patterns that were indistinguishable and were unlike the patterns obtained from the other isolates. Comparison of PFGE patterns of isolates from veterinary sources with patterns from MRSA recovered in human hospitals showed that the most frequently occurring pattern of MRSA from non-equine animals was indistinguishable from the predominant pattern obtained from the most prevalent MRSA strain in the human population in Ireland. However, the patterns of the isolates from horses were unlike any patterns previously reported in Irish studies of human isolates. This study shows that transmission of two strains of MRSA is occurring in veterinary practices in Ireland and that one strain may have arisen from human hospitals. The source of the second strain remains to be determined.