Predominance and genetic diversity of community- and hospital-acquired CTX-M extended-spectrum beta-lactamases in York, UK.

OBJECTIVES: This study was conducted to detect the presence of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae within the faecal flora of both community- and hospital-based patients in York and to characterize the bla(TEM), bla(SHV) and bla(CTX-M) genes present in these isolates. METHODS: One thousand faeces samples were collected and screened at York Hospital during October-December 2003. Ninety-five non-duplicate Enterobacteriaceae isolates resistant to third-generation cephalosporins were recovered; 22 isolates were selected for further study on the basis of a positive double disc diffusion test for ESBL production. Antibiotic susceptibility testing was performed to a range of antibiotics. The TEM, SHV and CTX-M genes were detected by PCR and the DNA sequenced. RESULTS: The distribution of ESBL-positive isolates from the hospital and community was 1.4:1. These included nine Escherichia coli, seven Enterobacter cloacae, four Citrobacter freundii and a single isolate each of Klebsiella spp. and Salmonella spp. A total of 17 isolates contained bla(CTX-M) (five bla(CTX-M-15), three bla(CTX-M-14) and nine bla(CTX-M-9)). ISEcp1 was present in isolates expressing CTX-M-14 and -15, but was absent upstream of In60-associated bla(CTX-M-9). E. coli isolates also contained either a bla(TEM-1) or bla(TEM-2), whereas six of the E. cloacae carried bla(SHV-12) and the Klebsiella spp. bla(SHV-36) in addition to bla(CTX-M-9). The single Salmonella spp. carried bla(SHV-12). CONCLUSIONS: The overall prevalence of ESBL in isolates of Enterobacteriaceae from York was 1.9%. ESBL-producing isolates were found in both the community and hospital, with the CTX-M type most common. This is also the first report of an ESBL-producing Salmonella in the UK.

Molecular epidemiology of Stenotrophomonas maltophilia isolated from clinical specimens from patients with cystic fibrosis and associated environmental samples.

Stenotrophomonas maltophilia was isolated from the respiratory tracts of 41 (25%) of 163 children attending our pediatric cystic fibrosis unit between September 1993 and December 1995. The extents of S. maltophilia contamination of environmental sites frequented by these patients were investigated with a selective medium incorporating vancomycin, imipenem, and amphotericin B. Eighty-two isolates of S. maltophilia were cultured from 67 different environmental sites sampled between January and July 1996. The organism was widespread in the home environment, with 20 (36%) and 25 (42%) of sampled sites positive in the homes of colonized and noncolonized patients, respectively. In the nosocomial setting, it was isolated from 18 (32%) sites in the hospital ward and from 4 (17%) sites in the outpatient clinic area. The most common sites of contamination were sink drains, faucets, and other items frequently in contact with water. All environmental and clinical isolates were genotyped with enterobacterial repetitive intergenic consensus sequences as primers. A total of 33 of the 41 patients were colonized with unique strains, and four pairs of patients shared strains. Further characterization by pulsed-field gel electrophoresis after digestion with XbaI found that there was no evidence of patient-to-patient transmission; however, there was some evidence that a small number of patients may have acquired the organism from the hospital environment. Resampling of environmental sites in the hospital ward in January 1997 revealed evidence of genetic drift, complicating the accurate determination of environmental sources for clinical strains. The source of the majority of S. maltophilia strains colonizing the respiratory tracts of these patients with cystic fibrosis remained uncertain but may have represented multiple, independent acquisitions from a variety of environmental sites both within and outside the hospital.

Transcontinental importation into the UK of Escherichia coli expressing a plasmid-mediated AmpC-type beta-lactamase exposed during an outbreak of SHV-5 extended-spectrum beta-lactamase in a Leeds hospital.

Sixteen strains of Escherichia coli with high-level resistance to extended-spectrum cephalosporins and other classes of antibiotic have been isolated at St James' University Hospital, Leeds. They produce up to three separate beta-lactamases: TEM-1, SHV-5 and, in five isolates, a plasmid-mediated AmpC-type enzyme. With the exception of carbapenems, the isolates reported in this study were resistant to all beta-lactam antibiotics including extended-spectrum cephalosporins and the monobactam aztreonam. There was evidence of the spread of a plasmid encoding SHV-5, particularly amongst patients on the liver transplant unit. Sensitivity to beta-lactam antibiotics in five isolates expressing the AmpC-type beta-lactamase was not restored by the beta-lactamase inhibitor clavulanic acid. These bacteria also carried blaSHV-5 on a large plasmid. PCR-amplification of the structural gene and digestion with restriction endonucleases demonstrated that the plasmid-mediated blaAmpC probably identified as BIL-1 using the criteria available. Four of the five patients carrying isolates that carried the plasmid-located blaAmpC gene had recently visited the Indian subcontinent and we presume that they returned carrying these bacteria. Restriction fragment length polymorphism analysis using pulsed field gel electrophoresis (PFGE) suggests that at least four distinct strains existed amongst these five isolates. The two isolates that had very similar PFGE patterns had different plasmid profiles and were isolated from different locations in the hospital and at different times. This study demonstrates the ease with which highly resistant bacteria can be imported into the UK and spread within hospitals.

Central venous line sepsis in the intensive care unit. A study comparing antibiotic coated catheters with plain catheters.

A randomized controlled clinical trial was undertaken to evaluate the efficacy of antibiotic bonded lines in the reduction of central venous catheter infection. One hundred and seventy-six plain and bonded catheters were inserted into one hundred and ten patients in an intensive care unit, many of whom were admitted with evidence of sepsis. The catheters used in the study group, which had been pre-treated by the manufacturers with the cationic surfactant tridodecylmethylammonium chloride, were bonded with vancomycin 1 g made up in 10 ml of water immediately prior to insertion. The catheters used in the control group were neither pre-treated nor bonded with vancomycin. Eighty percent of control group catheters were infected compared with 62% of study catheters (p = 0.01). The most common organism isolated was coagulase negative staphylococcus. We conclude that antibiotic bonding can reduce central venous catheter infection even in a patient population with a high incidence of sepsis.

Role of anti-pseudomonal antibiotics in the emergence of Stenotrophomonas maltophilia in cystic fibrosis patients.

A retrospective case-control study of 12 patients positive for Stenotrophomonas maltophilia and 24 age-sex-matched controls revealed that in the year prior to initial isolation, colonised patients spent more days in hospital and received more days of oral ciprofloxacin, intravenous anti-pseudomonal antibiotics, and nebulised aminoglycosides. They were also more likely to have grown Pseudomonas aeruginosa at some time in the past, despite there being no difference in current chronic infection with this organism. The role of anti-pseudomonal antibiotics in promoting Stenotrophomonas maltophilia colonisation in cystic fibrosis is discussed.

The acute phase protein response in mice does not show tolerance to recurrent sterile inflammation.

The response of acute phase proteins to repeated inflammatory stimuli was studied in BALB/c mice and Hylyne Dutch rabbits. Inflammation was produced by subcutaneous injections of turpentine/arachis oil twice weekly for three and a half weeks. Serum amyloid-P component (SAP) levels in the mice showed no significant decrease in the level of response following each injection and the pattern of response was the same in mice previously rendered tolerant to endotoxin. Haptoglobin levels in the rabbits also responded equally to repeated injections in two animals and showed a declining response in a third animal which became unwell during the experiment. The ability of experimental animals to continue to respond fully to repeated inflammatory stimuli supports the suggestion that the subnormal responses seen in certain chronic inflammatory conditions may reflect an underlying defect in the acute phase response rather than an adaptive change following chronic inflammation.

Bacterial contamination of intraocular lenses: the source of the bacteria.

In order to investigate potential sources for the bacterial contamination of intraocular lenses, specimens were taken for culture from a variety of sites. A swab from the lid margin, the operating room air, an intraocular lens which was allowed to rest on the eye, and the sodium hyaluronate were cultured during routine intercapsular lens implant surgery on 31 patients. Positive cultures were obtained from six intraocular lenses. Subtyping by three independent methods showed that isolates from five of these lenses were indistinguishable from bacteria cultured from the air. In the case of the sixth lens a bacterial isolate from the lid margin matched with that from the lens. Staphylococcus epidermidis was cultured from four lenses; Staphylococcus haemolyticus was also isolated from one of these four lenses and the remaining two lenses produced isolates of Staphylococcus aureus.