Dual infections with different Legionella strains.

In 2010 a case of a dual infection with Legionella pneumophila serogroup (sg) 1 and sg 3 was identified by culture of a blood sample collected from a female Austrian patient with septic pneumonia. Subsequently all 35 European National Legionella Reference Laboratories were interviewed regarding the frequency of dual infections in legionellosis. The Reference Laboratories in Denmark, the UK and Germany reported the detection of another 14 cases of dual infections with different Legionella strains between 2002 and 2012. Among the 15 cases, there were four cases with different Legionella species, six cases with different L. pneumophila serogroups, and five cases of dual infections with L. pneumophila sg 1 with different MAb-types. The median age of the 15 cases was 56 years and the male to female ratio 1:1.14. Six of the 15 patients were receiving immunosuppressive treatment following organ transplantation (n = 3) or for underlying haematological and solid malignancies (n = 3). Five of the 15 cases died within 30 days following diagnosis. Efforts to detect dual infections with different Legionella strains will improve our ability to correctly elucidate the causative sources of infection and enhance our understanding of the epidemiology of Legionella infections.

Fatal Pseudomonas aeruginosa pneumonia in a previously healthy woman was most likely associated with a contaminated hot tub.

Community-acquired pneumonia due to Pseudomonas aeruginosa in previously healthy individuals is a rare disease that is associated with high fatality. On 14 February 2010 a previously healthy 49-year-old woman presented to an emergency room with signs and symptoms of pneumonia, 2 days after returning from a spa holiday in a wellness hotel. Blood cultures and respiratory specimens grew P. aeruginosa. Despite adequate antimicrobial therapy, the patient died of septic multiorgan failure on day nine of hospitalization. On February 26, nine water samples were taken from the hotel facilities used by the patient: In the hot tub sample 37,000 colony-forming units of P. aeruginosa/100 ml were detected. Two of five individual colonies from the primary plate used for this hot tub water sample were found to be genetically closely related to the patient's isolates. Results from PFGE, AFLP and MLST analysis allowed the two lung isolates gained at autopsy and the whirlpool bathtub isolates to be allocated into one cluster. The patient most likely acquired P. aeruginosa from the contaminated water in the hotel's hot tub. The detection of P. aeruginosa in high numbers in a hot tub indicates massive biofilm formation in the bath circulation and severe deficiencies in hygienic maintenance. The increasing popularity of hot tubs in hotels and private homes demands increased awareness about potential health risks associated with deficient hygienic maintenance.

Etiology of acute gastroenteritis in three sentinel general practices, Austria 2007.

BACKGROUND: We studied the etiology of acute gastroenteritis in a village with a total population of approximately 6,000. This is the first study in Austria that has investigated a broad range of pathogens recovered from an unselected population of patients who had consulted general practitioners because of gastroenteritis. MATERIALS AND METHODS: In 2007, all patients who visited one of three local general practitioners for acute gastroenteritis were invited to provide stool specimens to be tested for Salmonella, Shigella, Campylobacter, enterohemorrhagic Escherichia coli (EHEC) (mTSB enrichment [R-Biopharm] followed by toxin ELISA plus culture), enteropathogenic E. coli (EPEC), Yersinia, Vibrio cholerae, Clostridium difficile (toxin plus culture), rotavirus plus adenovirus (RIDA) Quick Rotavirus/Adenovirus Combi test), Giardia duodenalis plus Cryptosporidium parvum (RIDA) Quick Cryptosporidium/Giardia Combi test), astrovirus (ELISA), and norovirus (reverse-transcriptase PCR). RESULTS: Stool specimens were provided by 306 patients (161 female) with acute diarrhea. The ages of the patients ranged from 1 to 89 years (mean 37, median 36). Pathogens were detected in 71 (23.2%) patients, with incidence peaks in February and June. Norovirus accounted for 36.0% of positive results, C. difficile for 18.7%, rotavirus for 17.3%, Campylobacter for 9.3%, Salmonella for 6.6%, adenovirus for 5.4%, G. duodenalis and C. parvum for 2.7% each, and Yersinia enterocolitica for 1.3%. No cases of shigellosis or infection with EHEC, EPEC, or astrovirus were diagnosed. Viruses accounted for 58.7% of the 75 positive results, bacteria for 36.0%, and parasites for 5.3%. CONCLUSION: Our study underlines a dominant role of norovirus and toxigenic C. difficile as etiologic agents of acute gastroenteritis among the patients of general practitioners.

Characterization of Clostridium difficile isolates using capillary gel electrophoresis-based PCR ribotyping.

We have developed a Clostridium difficile PCR ribotyping method based on capillary gel electrophoresis and have compared it with conventional PCR ribotyping. A total of 146 C. difficile isolates were studied: five isolates were reference strains (PCR ribotypes 001, 014, 017, 027 and 053); 141 were clinical isolates comprising 39 Austrian PCR ribotypes collected in the period 2006-2007 at 25 Austrian healthcare facilities. Capillary gel electrophoresis yielded up to 11 fragments per isolate and 47 ribotype patterns. All but one of the five PCR ribotypes of reference strains were clearly reflected in the chromatograms of capillary-based typing. Capillary gel electrophoresis divided 24 isolates belonging to PCR ribotype type 014 into seven subgroups, whereas subtyping the same isolates using multiple-locus variable-number tandem-repeat analysis yielded three unrelated subgroups, without obvious correlation to sr subgroups. Using a web-based software program (http://webribo.ages.at), we were able to correctly identify these 014 isolates by simply allocating the seven subgroup patterns to one ribotype, i.e. to PCR ribotype 014. We consider capillary gel electrophoresis-based PCR ribotyping to be a way of overcoming the problems associated with inter-laboratory comparisons of typing results, while at the same time substantially diminishing the hands-on time for PCR ribotyping.

Survey on legislation regarding wet cooling systems in European countries.

Wet cooling systems are often associated with large outbreaks of Legionnaires' disease. Several European countries have legislation for registering such systems. The authors aimed to obtain an overview of the situation in Europe. A questionnaire survey was sent to 35 of the countries that collaborate in the European Working Group for Legionella Infections. In two countries it was passed to a regional level (to three regions in both Belgium and the United Kingdom), so that 39 countries or regions were sent the survey; 37 responded. Nine countries stated having legislation for the registration of wet cooling systems. Separate legislation exists at a regional level for two regions in Belgium and all three regions in the UK, giving a total of twelve countries/regions with legislation. In nine of these countries/regions, the legislation has been introduced since 2001. All of these countries/regions require periodic microbiological monitoring between twice a year and weekly; in nine, the legislation requires periodic inspection of the systems. Regulations for the registration of wet cooling systems should be required by public health authorities. During an outbreak of legionellosis, a register of wet cooling systems can speed up the investigation process considerably. The authors believe that the European Centre for Disease Prevention and Control (ECDC) should take the initiative to propose European Community (EC) regulations for all Member States.

Characterization of clinical Clostridium difficile isolates by PCR ribotyping and detection of toxin genes in Austria, 2006-2007.

In order to assess the lethality of Clostridium difficile-associated disease (CDAD) and the PCR ribotypes prevalent in Austria, the Austrian Agency for Health and Food Safety requested isolates of C. difficile from patients in a structured but arbitrary sampling scheme. In the allocated period from February 2006 to January 2007, local hospital laboratories within each of the nine provinces were asked to submit C. difficile isolates from at least ten cases of CDAD. Confirmation of species identification, toxin detection, susceptibility testing against four antimicrobial agents and typing using a PCR ribotyping method were performed at the reference laboratory. In total, 149 isolates of putative C. difficile were submitted, from which 142 were included for study. Antimicrobial susceptibility patterns revealed resistance to clindamycin in 57% and high-level resistance to moxifloxacin in 38% of isolates tested. CDAD manifested as diarrhoea (including eight cases of bloody diarrhoea) in 126 cases (88.7%), as pseudomembranous colitis in 15 cases (10.6%) and as toxic megacolon in one case. Twelve of the 142 patients died within 30 days of specimen collection (8.45% lethality). A lethal outcome occurred in 2/15 cases (13.3%) when pseudomembranous colitis was present and in 10/126 cases (7.9%) in the absence of pseudomembranous colitis or toxic megacolon. Among the 142 isolates from 25 health-care facilities, 41 PCR ribotype patterns were found. The most frequent ribotypes were AI-5 (including six lethal cases out of 26 patients), 014 (two out of 24) and 053 (one out of 24). The typing patterns demonstrated the occurrence of clusters in hospitals.

Meticillin-resistant Staphylococcus aureus: occurrence of a new spa type in two acute care hospitals in Austria.

Typing multiply-resistant bacteria using molecular techniques is high priority for national health authorities. Routine typing of meticillin-resistant Staphylococcus aureus (MRSA) was initiated in Austria 2005 and was performed by sequence analysis of the variable X region of protein A gene (spa), characterisation of the mec gene (SCCmec) and testing for Panton-Valentine leukocidin (PVL), enterotoxins, toxic shock syndrome toxin and the epidermolytic toxin genes. Ten different spa types, including newly identified t2023, were found among 66 clinical MRSA isolates originating from two neighbouring hospitals under the same management. Spa type t2023 was initially isolated in December 2005 from hospital A, where it became the dominant spa type during 2006 (nine of 16 isolates). The occurrence of type t2023 in hospital B remained a unique event and could be epidemiologically linked to a patient transferred from hospital A. Spa type t2023 is very similar to spa type t001. An isolate of spa type t001 from hospital A showed an enterotoxin gene pattern, multilocus sequence type (MLST) and SmaI macrorestriction PFGE pattern indistinguishable from that of t2023. Epidemiological differences suggested that infection control measures can prevent MRSA cross-transmission. Hospital B had a more stringent MRSA isolation policy, a higher nurse:patient ratio and provided more resources for infection control than hospital A.

Surveillance of Legionnaires' disease in Austria.

Seven foreign cases of travel-associated Legionnaires' disease were associated with two neighbouring tourist villages in Austria between 1992 and 2004. The seven foreigners stayed in four hotels located in a geographical diameter of less than 10 km. Two cases were diagnosed in The Netherlands and five in the UK. The first case occurred in 1992, while the remaining cases clustered between August 2000 and April 2004. None of these cases was reported officially as part of a hotel-associated cluster, thereby highlighting several weaknesses of the infectious disease control systems involved.

Pan-European study on culture-proven Legionnaires' disease: distribution of Legionella pneumophila serogroups and monoclonal subgroups.

This pan-European study included unrelated strains of Legionella pneumophila obtained from 1335 cases of Legionnaires' disease. The isolates were serotyped into the serogroups 1 to 15 by monoclonal antibodies (MAb) and/or rabbit antisera. Additionally, MAb subgrouping was undertaken for isolates belonging to serogroups 1, 4, and 5. Monoclonal types of serogroup 1 were subdivided as having, or not having, the virulence-associated epitope recognized by the MAb 3/1 (Dresden Panel). This epitope is not present on strains belonging to any other serogroups. Taking all Legionella incidents together, MAb 3/1-positive cases were most frequent (66.8%); 11.7% of the isolates belonged to MAb 3/1-negative serogroup 1 subgroups and 21.5% to other serogroups, with serogroups 3 and 6 predominating. Among all serotypes discriminated in this study, monoclonal subtype Philadelphia was the most frequent. If categories of infection were considered, the proportion of MAb 3/1-negative strains differed significantly ( P<0.0005) between community-acquired cases (139/510; 27.3%) and travel-associated (42/295; 14.2%) or hospital-acquired infections (176/329; 53.5%). Moreover, taking distribution in different European areas into account, the proportion of MAb 3/1-negative strains was significantly higher in the Scandinavian region than in the Mediterranean countries or the UK for both community-acquired (48.7% vs. 18.6% or 12.0%; P<0.0005) and nosocomial cases (87.7% vs. 32.6% or 52.6%; P

The influence of hand hygiene prior to insertion of peripheral venous catheters on the frequency of complications.

In a prospective multi-centre study involving 1132 peripheral venous catheters in three hospitals, the relationship between various measures of hand hygiene before insertion of peripheral venous catheters and the frequency of infectious complications', such as local reddening, swelling, pain, purulence and fever of unknown origin, were analysed. For documentation of the relevant data, special protocol forms, one for each catheter, were filled in at the time of insertion and removal of catheters. In comparison with simple hand washing, disinfection of hands before the insertion or wearing of gloves resulted in significantly fewer complications (relative risk 0.59 and 0.66, respectively). Normal hand washing was no better than no hand hygiene (relative risk 1.13), with regard to reduction of complications. This underlines the necessity of employing more effective measures of hand hygiene. The frequency of complications was dependent on the duration of peripheral venous catheterization. Catheters inserted in the operating room had a significantly lower risk of complications than catheters inserted on the ward or in the outpatient unit.

Implementation of a molecular typing system to support epidemiological investigations in the tuberculosis health care system in Vienna.

Tuberculosis continues to be one of the predominant infectious diseases. Effective control of its spread requires that sources of infection and routes of transmission be disclosed as quickly as possible. At present such investigations are still performed by conventional epidemiological methods. In the recent past, however, molecular typing systems were added to the spectrum of epidemiological tools. Unfortunately, they were applied to retrospective investigations rather than used as an aid in the health care system. In this study, 515 Mycobacterium tuberculosis strains isolated during 1997 and 1998 in Vienna were analysed by spoligotyping, a molecular technique requiring no further cultivation of mycobacteria. The study was aimed to assess the suitability of the method as a quick means of disclosing new cases. Thus, clusters obtained by spoligotyping were analysed along with demographic and epidemiological data and compared with clusters obtained by conventional epidemiological techniques alone. In addition, spoligotype-forming clusters were matched with an international database containing spoligotypes from four different studies. Of 515 isolates, 107 showed an unique pattern. The remaining 408 isolates were distributed into two large clusters of 82 and 73 isolates and into 49 smaller ones consisting of 2 to 33 isolates each. The two spoligotypes forming the large clusters were identical with the most prevalent spoligotypes in the world. Therefore, for the tuberculosis authorities, information was only gained by excluding rather than tracing possible ways of transmission. Twenty-two of the 49 spoligotypes forming smaller clusters were identical with strains found in other parts of the world. Seventeen of 22 infection chains assumed by conventional investigations were confirmed by spoligotyping. In small clusters, an additional 24 infections were assumed due to similarities such as living conditions or socioeconomic status. In 27 clusters, all patients sharing the same strain belong to the same country or geographical area. In conclusion, spoligotyping proved suitable as an early guide in conventional investigations to trace routes of M. tuberculosis transmission in a community. However, when a strain isolated from a patient belongs to a spoligotype shared by many isolates, a second molecular typing method is required.

Infant tuberculosis in Austria--trend reversal since 1990?

Since 1990 a relatively high number of cases of childhood tuberculosis has been observed in Austria, mainly occurring in the age-group of 0-4 years. Within this group most cases were registered in 1995. Since the beginning of 1995 the establishment of a lab-supported nationwide data collection system enables a more detailed recording of the cases diagnosed. Out of the 85 cases with infant tuberculosis registered in 1995 and 1996, 66 were diagnosed with pulmonary manifestation. In 45 cases tuberculosis was proven by culture. In nine (20%) of these cases the most likely route of infection has appeared to be direct transmission from an adult in the same household suffering from culture proven tuberculosis in the same year. For three of the cases the DNA of the isolated Mycobacterium tuberculosis strains from the adult and the infant was typed using RFLP analysis. In each case identical strains could be demonstrated.

[Efficacy of various methods for preoperative vaginal antisepsis]. / Zur Effizienz von Verfahren für die präoperative Vaginalantiseptik.

In a prospective clinical study we investigated 115 patients prior to vaginal surgical interventions to determine the antimicrobial efficacy of six different procedures for vaginal antisepsis. To sample the microorganisms we used a cotton swab moistened with a neutralising fluid. Immediately after the time of action of the antiseptic procedures (3 minutes), providone-iodine solution, applied undiluted or diluted 1:10, yielded the strongest median reduction of the vaginal flora (log RF 3.60 and 2.68, respectively). Of three detergents with antiseptic efficacy, octenidine 0.1% was the most efficient formula (log RF 2.32). After 30 minutes the log reduction factors (log RF) of almost all procedures (log RF 2.79-3.25) were in a fairly close range, excepting chlorohexidine 0.05% (log RF 2.07). Overall, the antiseptic detergents showed a marked residual effect, which was less pronounced, if at all, with providone-iodine solutions. A germ-reducing effect of povidone-iodine vaginal suppositories, applied 2 to 3 hrs prior to surgery, was not confirmed, while additional findings indicated that providone-iodine solution applied with the help of a vaginal douche yields a similarly strong germ reduction as the application by means of a ball swabs.

[Genomic DNA fingerprints of Legionella pneumophila serogroup 2 strains as an epidemiologic marker]. / Genomische DNS-Fingerprints von Legionella-pneumophila-Serogruppe-2- Stämmen als epidemiologischer Marker.

Using pulsed-field gel electrophoresis, DNA fingerprints of eleven Legionella pneumophila isolates of serogroup 2 were generated. It was shown that two strains from a patient suffering from pneumonia as well as three environmental strains isolated from the shower in the hotel where the patient stayed 5 days before his illness were identical. Six strains of the same serogroup isolated from other sources were clearly separated. Thus, DNA fingerprints by pulsed-field gel electrophoresis are excellent epidemiological markers for the rarely occurring serogroup 2 of Legionella pneumophila.

Legionella pneumonia in transplant recipients: a cluster of cases of eight years' duration.

Infection with Legionella is often encountered in immunosuppressed patients, especially in recipients of renal allografts. From January 1985 until April 1993 14 cases of nosocomial legionella pneumonia were diagnosed (four by culture, 10 by serological methods) on the surgical transplantation unit of Innsbruck University Hospital. All isolates from patients and from the building's hot water were found to be Legionella pneumophila serogroup 1. They were indistinguishable from each other by monoclonal antibody subtyping and restriction fragment length polymorphism pattern and thus indicated a series of infections originating from the same source during a period of more than 8 years. Repeated efforts to control Legionella by raising the temperature in the hot water lines failed to bring permanent success. Replacing the central hot water supply with small electric water heaters installed in the patient rooms on the transplant ward now seems to have reduced the incidence of legionellosis on this unit. However, further infections occurring in transplant patients in other surgical departments in the same building indicate that a major renovation of the whole surgical building's hot water system is necessary.

Genital antisepsis--test methodology and efficacy of povidone-iodine.

Indications for antiseptic prophylaxis include use prior to urinary catheterization and other transurethral instrumentations, diagnostic or therapeutic instrumentation of the cavum uteri, and operations on the external genitalia and the vagina. Indications for antiseptic therapy include treatment of wounds and of infections of the genital tract and also include treatment of the vaginas of pregnant women to prevent infection in the newborn. For prophylactic antisepsis the aim is the optimal reduction of potentially pathogenic microorganisms. In some fields of application, e.g. before urinary catheterization, an immediate effect on the mucous membrane is required, but on other occasions, such as transvaginal operations, an additional sustained effect is desired. Testing the efficacy of mucous membrane antiseptics, especially for the genital tract, necessitates the establishment of standardized test methods. The variability in vaginal flora at various ages makes it reasonable to study women aged 20-50 years. Studies presented in this paper indicate that microorganism sampling using a cotton swab moistened with neutralizing fluid can be favoured compared to using a rinsing technique and that anaerobic culture techniques enable the measurement of the high reduction factors achieved by very efficient antiseptic procedures. Test methods validated for hand disinfectants are used for calculations and statistical evaluation. The antimicrobial efficacy of six vaginal antiseptic procedures were compared in patients prior to vaginal surgery. Three minutes after treatment, the highest mean reduction (log RF) of the normal vaginal flora as well as of potentially pathogenic microorganisms was obtained by povidone-iodine solution undiluted and povidone-iodine solution 1:10 (log RF 3.60 and 2.68, respectively). Out of three detergents with antimicrobial efficacy, octenidine 0.1% was the most effective preparation (log RF 2.32). Chlorhexidine 0.1%, hexetidine 0.1% and chlorhexidine 0.05% led to lower reduction factors (log RF 1.80, 1.62 and 1.02, respectively). After 30 minutes the log reduction factors were approximating each other in nearly all procedures (log RF 2.79-3.25) except the log RF derived from the procedure performed using chlorhexidine 0.05% (log RF 2.07). Povidone-iodine solutions seem to be the method of choice for mucous membrane antisepsis where an immediate effect is required. If a long period of action is needed all procedures examined, except chlorhexidine 0.05%, are acceptable.

Six cases of travel-associated Legionnaires' disease in Ischia involving four countries.

The detection of travel-associated legionellosis can be extremely difficult; hence, an extensive case investigation is recommended in pneumonia-striken travellers and tourists, who are particularly at risk of acquiring the disease. On the Island of Ischia (Isola d'Ischia, Naples, Italy) a total of six cases of Legionnaires' disease occurred from 1986 to 1990. All patients (one man and two women from Germany, one Austrian woman, one Swiss man, and one Italian woman) had taken thermal baths and stayed in local hotels; they all experienced severe pneumonia, and three of them died. These cases were associated with hotels, and the hot-water supply was presumed to have transmitted the infection. Remedial procedures were applied to the hot-water plumbing of the hotels according to the WHO recommendations and were proved to be effective. The occurrences described in this paper stress the importance of rapid and accurate reporting of diagnosed cases to the country where the infection was probably acquired, in order to ensure early detection of endemic foci and emerging clusters of legionellosis.

Educational programmes for infection control in Austria.

Educational aims and strategies (simply arousing awareness, sensitivity and understanding; and/or training in practical skills and knowledge; or the ability to teach infection control, and to convince those taught) depend on the target group. Infection control is part of the curriculum for students of medicine and other health care professions, and is included in course examinations. Postgraduate doctors may seek training on courses which are organized by the Hygiene Institute of the University of Vienna in co-operation with the Austrian Society of Hygiene, Microbiology and Preventive Medicine. Registered nurses may enroll in the Austrian Nurses' Association training scheme (6 weeks of theory with professional work for 2 years), leading to approval as Hygieneschwester/-pfleger. Postgraduate in-hospital education for all health-care professions occurs in many Austrian hospitals, with resources from Vienna and Linz. Hospital managements, health authorities and politicians are influenced via their own educational activities and via publications.

Discrimination between antibodies to HIV-1 and HIV-2 in sera from northern Zaire.

136 selected sera from Northern Zaire were screened for antibodies against HIV-1 and HIV-2 using the ELISA method. Reactive sera were confirmed with commercially available Western Blots and additional tests. A data base was used for evaluation of the results. The sera were collected in the town Isiro and in remote rural areas. 36 sera were reactive in the HIV-1 ELISA (ELAVIA-1), 19 of them were confirmed in the HIV-1 Western Blot (Biorad). 21 sera were reactive in the HIV-2 ELISA, but they were not confirmed as HIV-2-specific in three HIV-2 Western Blots (Diagnostics Pasteur, Biorad, Paul-Ehrlich-Institut).