Investigation and response to an outbreak of Neisseria meningitidis serogroup Y ST-1466 urogenital infections, Australia.

Abstract: In 2023, an increased number of urogenital and anorectal infections with Neisseria meningitis serogroup Y (MenY) were reported in New South Wales (NSW). Whole genome sequencing (WGS) found a common sequence type (ST-1466), with limited sequence diversity. Confirmed outbreak cases were NSW residents with a N. meningitidis isolate matching the cluster sequence type; probable cases were NSW residents with MenY isolated from a urogenital or anorectal site from 1 July 2023 without WGS testing. Of the 41 cases, most were men (n = 27), of whom six reported recent contact with a female sex worker. Five cases were men who have sex with men and two were female sex workers. Laboratory alerts regarding the outbreak were sent to all Australian jurisdictions through the laboratories in the National Neisseria Network. Two additional states identified urogenital MenY ST-1466 infections detected in late 2023. Genomic analysis showed all MenY ST-1466 sequences were interspersed, suggestive of an Australia-wide outbreak. The incidence of these infections remains unknown, due to varied testing and reporting practices both within and across jurisdictions. Isolates causing invasive meningococcal disease (IMD) in Australia are typed, and there has been no MenY ST-1466 IMD recorded in Australia to end of March 2024. Concerns remain regarding the risk of IMD, given the similarity of these sequences with a MenY ST-1466 IMD strain causing a concurrent outbreak in the United States of America.

Difficulties in detection and identification of Enterococcus faecium with low-level inducible resistance to vancomycin, during a hospital outbreak.

Between June and November 2004, a vancomycin-resistant Enterococcus faecium (VRE) strain was isolated from 13 patients in the haematology/bone marrow transplant unit. There were difficulties in identifying the organism, which had low-level, inducible vancomycin resistance, and standard screening methods did not reveal carriage in patients or their contacts. These technical failures led to spread of VRE and delays in providing appropriate management, which might otherwise have been avoided. Therefore, we reviewed our laboratory methods and compared three identification systems to determine which would best identify this VRE strain. The VITEK 2 (BioMerieux) correctly identified, as E. faecium, only two of 16 isolates, whereas API Rapid ID 32 Strep (BioMerieux) and Phoenix 100 (Becton Dickinson and Co.) correctly identified 13 of 15 and 12 of 13 isolates tested, respectively. Isolates from urine, tested by the CLSI disk diffusion method, were apparently susceptible or of intermediate susceptibility to vancomycin, upon primary testing. VITEK 2 and Phoenix 100 identified all isolates as vancomycin-resistant, although the MICs, measured by Etest, were in the susceptible range for three of 16 isolates. Reducing the vancomycin concentration in screening media substantially increased the sensitivity for detection of VRE. Isolates were characterized as genotype vanB2/3 by PCR and were indistinguishable from each other by pulsed-field gel electrophoresis. VRE with low-level inducible resistance can be missed by routine screening methods. Better identification and screening methods for detection of low-level vancomycin resistance are needed to improve surveillance and prevent transmission of VRE.

Antimicrobial susceptibility of Bartonella henselae using Etest methodology.

OBJECTIVES: Bartonella henselae is a fastidious slow growing pathogen which is seldom cultured in the laboratory. Previous descriptions of antimicrobial susceptibility have been largely limited to feline isolates and/or laboratory reference strains, with no accounting for genotypic or phenotypic diversity. METHODS: An optimal method of antimicrobial susceptibility testing by Etest was established to compare the antimicrobial susceptibilities of 12 different isolates of B. henselae, 5 human and 7 feline, which have previously been well characterized by 16S rRNA sequencing, multi-locus sequence typing (MLST), phase variation and passage number. RESULTS: No difference in susceptibility could be attributed to differences in genotype, source of the isolate or passage number. Where comparisons were drawn with previously published results, these were found to be concordant. CONCLUSIONS: We conclude that antibiotic susceptibility can be determined by a simple Etest method for B. henselae isolates. This method is reproducible among diverse strains, and is sufficiently predictable that generalizations can be confidently made about optimal antibiotic choices.

Altered expression of CD88 and associated impairment of complement 5a-induced neutrophil responses in human immunodeficiency virus type 1-infected patients with and without pulmonary tuberculosis.

The effect of infection with human immunodeficiency virus type 1 (HIV patient group), infection with Mycobacterium tuberculosis (TB patient group), and coinfection with both of these organisms (HIV/TB patient group) on the expression of CD88 on polymorphonuclear leukocytes (PMNL) was determined by using a receptor-specific monoclonal antibody and flow cytometry. A significant reduction in the fluorescence intensity of CD88 on PMNL was observed in the HIV and HIV/TB groups, compared with both the healthy donor (HD) and TB groups. Furthermore, when degranulation of PMNL was induced by ligation of CD88 by complement 5a (C5a), a large proportion of patients in the HIV and the HIV/TB groups was found to have reciprocal degranulation responses. Patients in the 2 HIV groups also were found to have significantly reduced C5a-induced chemotactic responses and significantly elevated peripheral levels of C5a des Arg, compared with the HD and TB groups. These differences may contribute to the increased susceptibility of HIV-1-infected individuals to secondary microbial infections.

Adjunctive salvage therapy with inhaled aminoglycosides for patients with persistent smear-positive pulmonary tuberculosis.

A proportion of patients with drug-resistant and drug-susceptible tuberculosis (TB) have sputum that is smear and culture positive for Mycobacterium tuberculosis for a prolonged period of time, despite conventional therapy. Among such patients with refractory TB, an unblinded, observational study was undertaken that used conventional TB therapy and adjunctive aerosol aminoglycosides. Patients with persistent smear- and culture-positive sputum for M. tuberculosis (despite > or =2 months of optimal systemic therapy) were selected for adjunctive treatment via inhalation with aminoglycosides, and microbiological responses were monitored. Thirteen of 19 patients converted to smear negativity during the study: 6 of 7 with drug-susceptible TB and 7 of 12 with drug-resistant TB. Among patients with drug-susceptible TB, the median time to sputum conversion was 23 days, a shorter time than for a population of historical control patients. Recurrent infection was not observed. Adjunctive aerosol aminoglycosides may expedite sterilization of sputum among certain patients with refractory TB and diminish the risk of transmission.

Distribution of the human immunodeficiency virus coreceptors CXCR4 and CCR5 on leukocytes of persons with human immunodeficiency virus type 1 infection and pulmonary tuberculosis: implications for pathogenesis.

Expression of CXCR4 was significantly reduced from normal on all cell subsets of persons with pulmonary tuberculosis (TB group), with HIV-1 infection (HIV group), and those with both infections (HIV/TB group), except for on monocytes in the HIV group. The reductions were most notable in the two TB groups. Interestingly, the duration of antituberculosis treatment was significantly negatively correlated with the expression of CXCR4 on CD4+ and CD8+CD45RO+ cells, monocytes and NK cells, viral load, and proportions of CD38-expressing CD8+ lymphocytes, in HIV/TB patients. By contrast, CCR5 expression on most cell subsets analyzed was increased in all the disease groups, except for on monocytes in the two TB groups. There was no change in CCR5 expression on CD4+ cells when based on the disease groupings. However, higher proportions of CD4+CD45RA+ and CD8+ lymphocytes as well as B cells expressing CCR5 correlated with advancing HIV-1 disease, as did decreased proportions of CXCR4-expressing CD4+CD45RA+ cells.

Clinical and radiological features of South African patients with tuberculomas of the brain.

Intracranial tuberculomas are a rare complication of tuberculosis that typically occurs in immunocompromised patients not treated previously for tuberculosis. We identified tuberculomas in 12 patients (11 of whom were infected with human immunodeficiency virus) at a hospital in Johannesburg, South Africa. Responses to antituberculous therapy were good, often despite the presence of large lesions, and surgery was not considered necessary in any of the patients.

A comparison of outbreak- and nonoutbreak-related multidrug-resistant tuberculosis among human immunodeficiency virus-infected patients in a South African hospital.

Nosocomial multidrug-resistant tuberculosis (MDR-TB) in human immunodeficiency virus (HIV)-infected people is recognized in Europe and America. We report the first such outbreak in South Africa. Six hospitalized women, identified by DNA fingerprinting, were infected with an outbreak strain of MDR-TB while receiving treatment for drug-susceptible tuberculosis. The putative source case was identified as an HIV-positive woman who underwent prolonged hospitalization for chronic cavitary tuberculosis. Compared with other HIV-positive patients in the hospital, outbreak patients were more immunocompromised, had fewer cavitary lung changes, and were less likely to have been treated before. They had high fevers, infiltrative patterns on chest radiographs, and a mean survival of 43 days. When individual isolation is not possible, separating highly immunocompromised patients with first-time tuberculosis from previously treated patients with cavitary lesions and from those with established drug resistance may reduce nosocomial transmission.

Primary HIV infection diagnosed in South Africa masquerading as another tropical disease.

Eleven patients referred to a hospital in South Africa with suspected tropical diseases such as malaria, typhoid fever and South African tick bite fever were found to be suffering from primary human immunodeficiency virus (HIV) infection. Hospital records were reviewed retrospectively in those acutely ill, febrile patients where a clinical suspicion of HIV seroconversion existed and no other diagnosis could be found. A history of recent travel, particularly to malarious areas, was given by most of these patients. The clinical presentation was dominated by high fevers and headaches. The most helpful pointers to primary HIV infection included a characteristic palatal enanthem, leucopenia and thrombocytopenia. Ironically, the history of recent travel appeared to have confounded the diagnosis despite the fact that travel has often been associated with the acquisition of HIV in Africa. Recognition of primary HIV infection masquerading as a tropical disease may result in more frequent diagnosis of this serious condition.

Factors related to in-hospital deaths in patients with tuberculosis.

BACKGROUND: Deaths from tuberculosis (TB) continue to occur despite the availability of effective antimicrobial agents. Multidrug resistance, human immunodeficiency virus (HIV) infection, and delayed therapy have been implicated. OBJECTIVE: To examine clinical factors associated with in-hospital death in patients with active TB. METHODS: A retrospective case-control study was performed on patients admitted to a government hospital in Johannesburg, South Africa, used as a referral center for patients with TB. Eighty patients admitted with TB who died during hospitalization were matched with 80 similar patients with TB who survived hospitalization. Clinical, demographic, and radiological characteristics of each group were compared. RESULTS: In-hospital fatalities were associated with female sex (P=.01), lower admission hemoglobin level (P<.01), and weight (P<.01), and a trend to more extensive infiltrative patterns on chest radiographs. Multidrug resistance, extrapulmonary disease, and HIV infection were unexpectedly not related to in-hospital mortality. High mortality in the first weeks of admission suggested that late presentation was a major factor for in-hospital death. The HIV-infected participants in the study showed less drug resistance than HIV-negative patients (P=.07), equivalent extents of infiltrative patterns on chest radiographs, but much less cavitation and fibrosis (P<.01). CONCLUSIONS: Clinical predictors of early mortality from TB included anemia, low body weight, and extensive infiltrates, while multidrug resistance and HIV infection were not significant factors. Previous exposure to TB and delayed presentation may have influenced our findings. Since patients present late in their illness, aggressive case finding would be important in controlling TB in this population.

Developing an acute pain service in a multicultural setting.

Development of an Acute Pain Service in a multicultural environment can be a difficult and challenging endeavor. In addition to concerns about communicating with patients who speak a foreign language, the problem of integrating staff from many different backgrounds must be faced. Education for both patients and staff must be innovative, multifaceted, and individualized. At King Faisal Specialist Hospital and Research Centre in Riyadh, Saudi Arabia, the past 2 years have been a time of challenge and growth as an interdisciplinary team developed a pain service that meets the hospital's unique needs while fulfilling the goal of improved pain management for the patients.