Vancomycin-resistant enterococcus bacteraemia in an endemic region: clinical features and genomic analysis: a 12-year cohort.

BACKGROUND: Vancomycin-resistant enterococci (VRE) are important nosocomial pathogens with increasing prevalence worldwide. Hospitals in Jerusalem, Israel are known to have high rates of VRE carriage. However, the clonicity of this pathogen in endemic areas remains unclear. METHODS: The medical files of patients with VRE bacteraemia (N=182) hospitalized in the three major hospitals in Jerusalem between 2009 and 2020 were reviewed. These were compared with 100 patients with vancomycin-susceptible enterococcus (VSE) bacteraemia during the same period, and their clinical and demographic characters were analysed. Whole-genome sequencing (WGS) of the VRE isolates was performed, and the results were analysed considering the demographic, epidemiologic and clinical outcome data. RESULTS: Patients with VRE bacteraemia had higher rates of central line use, haematologic malignancy and immunosuppression compared with patients with VSE bacteraemia (63% vs 27%, P<0.001; 25% vs 13%, P=0.02; 24% vs 13%, P=0.04, respectively). Patients with VRE bacteraemia had significantly higher 7- and 30-day in-hospital mortality rates (31% vs 18%, P= 0.02; 57% vs 34%, P<0.001, respectively) and a longer mean hospital stay (39 vs 24 days, P=0.005) than patients with VSE bacteraemia. The WGS results of VRE isolates showed diversity rather than endemicity of a single clone. No clones were associated with specific ethnicity, geographical distribution or worse prognosis. CONCLUSIONS: WGS revealed the occurrence of small unrelated outbreaks rather than the expansion of large clusters in Jerusalem. VRE bacteraemia was found in sicker patients, and was associated with higher mortality and longer hospitalization compared with VSE bacteraemia.

Streptococcus bovis new taxonomy: does subspecies distinction matter?

Bacteremia with Streptococcus bovis/equinus complex strains is associated with hepatobiliary disease, colorectal lesions (CL), and infective endocarditis (IE). This study addressed the clinical significance of subspecies distinction of previously designated S. bovis blood culture isolates according to the updated nomenclature. During 2002-2013, all blood culture isolates previously designated as S. bovis were recultured and identified using 16S rRNA gene sequencing and MALDI-TOF (Bruker BioTyper and Vitek MS, bioMérieux). Clinical data of patients aged ≥18 years were reviewed. A review of four recent case series was performed as well. Forty blood isolates were identified using 16S rRNA sequencing. Twenty-six bacteremic patients had S. gallolyticus ssp. pasteurianus, six had S. gallolyticus ssp. gallolyticus, two had S. gallolyticus ssp. macedonicus, and six had S. infantarius bacteremia. Species diagnosis using Vitek and bioMérieux MALDI-TOF technology was applicable in 37 and 36 samples, respectively, and was successful in all samples (100 %). Subspecies identification was confirmed in 30 (83 %) samples (as compared with 16S rRNA sequencing detection). IE was diagnosed in 22 (59 %) patients and CL in 8 (20 %) patients. Both complications were associated with all subspecies. Combining our results with those of four recent series resulted in, overall, 320 bacteremic cases, of which 88 (28 %) had CL and 66 (21 %) had IE. All 'bovis/equinus' complex subspecies were associated with CL or IE. From a clinical point of view, species diagnosis using MALDI-TOF MS should suffice to warrant consideration of transesophageal echocardiography and colonoscopy.

Ten years with colistin: a retrospective case series.

OBJECTIVE: At the Shaare Zedek Medical Center, we have been using colistimethate sodium (CMS) for empiric as well as pathogen-directed treatment. We present our 10-year experience. METHODS: We conducted a retrospective case-series analysis of patients admitted from 1 January 2004 through 1 May 2014 who received at least one dose of CMS. Patient characteristics analysed for all admission for which patients received CMS, included: age, number of re-admissions, admission ward, renal function, disposition and microbiology results. Overall trend in defined daily dose (DDD) for CMS and resistant isolates was analysed. RESULTS: A total of 5603 admissions met inclusion criteria. Patients' mean (±SD) age was 80 ± 14 years, 1162 (48%) of the admissions were from a healthcare facility and 4367 (78%) of the admissions were to general Internal Medicine wards. The median number of hospital admissions per patient was 5, median admission and discharge creatinine (mg/dl) were 1.05 and 1.01, respectively; 2.3% of admissions required first-time dialysis. The discharge rate from the hospital was 58.4%. Excluding intrinsically CMS-resistant gram-negative organisms, bloodstream and urine isolates were 98% and 100% susceptible, respectively. CMS use (DDDs) increased during the study (p for trend = 0.04) without significant increase in incidence of multidrug-resistant organisms. CONCLUSIONS: Colistimethate sodium use at our institution has increased during this 10-year period. Nevertheless, there is no increasing trend in CMS-resistant organisms, 58% of the patients were discharged alive, and we did not observe significant nephrotoxicity in patients prescribed CMS. CMS should be reserved for microbiologically confirmed extensively drug-resistant gram-negative infections.

A multicenter study of the clonal structure and resistance mechanism of KPC-producing Escherichia coli isolates in Israel.

Little is known about the molecular epidemiology of Klebsiella pneumoniae carbapenemase-producing Escherichia coli (KPCEC). We aimed to describe the clonal structure and resistance mechanisms of KPCEC in a multicenter study. The study included 88 isolates from four medical centres in Israel: Tel Aviv Medical Center (n = 17), Laniado Medical Center (n = 12), Sha'are-Zedek Medical Center (n = 38), and Rambam Medical Center (n = 21). Twelve (14%) KPCEC were from clinical sites and 86% from surveillance cultures. The clonal structure was studied by pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST) and was highly diverse, with 79 and 45 different PFGE types and STs, respectively. The most common clones were ST-131 and ST-410, identified in 21 isolates (23%). Dominant clonal complexes (CCs) were CC131 (n = 16), CC410 (n = 14), CC10 (n = 17), and CC-69 (n = 6). The blaKPC-2 and blaKPC-3 genes were identified in 68 and 20 isolates, respectively. All isolates were non-susceptible to ertapenem; 16 (18%) and 35 (40%) isolates were susceptible (minimal inhibitory concentration ≤1 mg/L) to imipenem and meropenem, respectively. Isolates were susceptible to colistin, amikacin, ciprofloxacin, gentamicin, and trimethoprim-sulfamethoxazole in 100%, 87%, 28%, 27%, and 21% of the cases, respectively. blaKPC-Harbouring plasmids from Tel Aviv Medical Center as well as from six CC-131 isolates from the other centres were studied by Inc and pMLST typing. Sixteen of the 20 blaKPC2-harbouring plasmids were of identical type, IncN-pMLST ST-15. In conclusion, the clonal structure of KPCEC in Israel is characterized by the predominance of known international extended-spectrum ß-lactamase-producing clones and by high intra- and inter-institutional diversity. This suggests that in Israel, clonal spread does not play a major role in the dissemination of KPCEC.

Risk factors for bacteriuria with carbapenem-resistant Klebsiella pneumoniae and its impact on mortality: a case-control study.

BACKGROUND: The objective of this study was to evaluate the mortality of and risk factors for bacteriuria due to carbapenem-resistant Klebsiella pneumoniae (CRKp) versus carbapenem-susceptible K. pneumoniae (CSKp) producing extended spectrum ß lactamase (ESBL). METHODS: This was a retrospective case-control study in which 135 case-patients with bacteriuria due to CRKp were compared with 127 control patients with CSKp producing ESBL. In a first step, multivariate Cox regression and Kaplan-Meier survival analysis models were used to determine the difference in mortality between the two groups and risk factors for mortality. In a second step, a univariate analysis was used to identify risk factors for CRKp colonization. RESULTS: There were no significant demographic or clinical differences between the groups. In-hospital mortality in the study and control groups was 29 and 25 %, respectively (non-significant difference). Multivariate analysis revealed that the most important risk factor for mortality in both groups was being bed ridden [hazard ratio 2.2, 95 % confidence interval (CI) 1.23-3.93; P = 0.008]. Patients with CRKp bacteriuria had a longer hospitalization time with a mean ± standard deviation of 28 ± 33 days compared to 22 ± 28 days in the control group (P < 0.05). Several univariate risk factors for acquiring CRKp bacteriuria were identified: antibiotic use [odds ratio (OR) 1.93, 95 % CI 1.18-3.17, p = 0.008], especially colistin (OR 2.04, 95 % CI 1.04-4.02; P = 0.036), presence of a urinary catheter (OR 2.09, 95 % CI 1.2-3.63; P = 0.008), surgery (OR 3.94, 95 % CI 1.85-8.37; P = 0.0002), invasive procedures (OR 3.06, 95 % CI 1.61-5.8; P = 0.0004), and intensive care unit admission (OR 2.49, 95 % CI 1.18-5.37; P = 0.015). CONCLUSION: Bacteriuria caused by CRKp as compared that caused by CSKp was not found to be a risk factor for death.

Improving implementation of infection control guidelines to reduce nosocomial infection rates: pioneering the report card.

BACKGROUND: Two detailed checklists were developed, based on published infection control guidelines, for daily use by infection control practitioners in departments and operating rooms. AIM: To assess the impact of the checklists on nosocomial infection rates in three hospitals over the course of one year. METHODS: The checklists included 20 subheadings (± 150 items). Project nurses conducted rounds in the study (but not control) departments; during each round, the nurses selected 15-20 items for observation, marked the checklists according to appropriateness of observed behaviour and provided on-the-spot corrective education. Rates of adherence to the checklist, antibiotic use, number of obtained and positive cultures, and positive staff hand and patient environment cultures were reported monthly as a report card to relevant personnel and administrators. The rate of nosocomial infections was determined in the first and last months. RESULTS: The baseline nosocomial infection rate was similar in the study and control departments: 37/345 (11%) and 26/270 (10%) respectively. In the last month, the rate in the study department decreased to 16/383 (4%) (P<0.01); in the control it decreased insignificantly to 21/248 (8%) (not significant). No significant trends were detected in the number of obtained cultures, positive cultures, or antibiotic use. Adherence to guidelines ranged from 75% to 94% between the hospitals (P<0.001): the overall rate increased from 80% to 91% (P<0.01). CONCLUSIONS: The use of checklists during the conduct of infection control rounds, combined with monthly reports, was associated with a significant decrease in nosocomial infections in study departments.

Relapsing fever borreliosis in Eurasia--forgotten, but certainly not gone!

Tick-borne relapsing fever (TBRF) has been reported in Eurasia and attributed mainly to Borrelia persica, although other entities have also been described. Ornithodoros tholozani is the most important tick vector, found in India and Kashmir, the southern countries of the former USSR, Iran, Iraq, Syria, Jordan, Turkey, Israel, Egypt, and Cyprus. It inhabits caves, ruins, and burrows of rodents and small mammals. In the northern countries, O. tholozani also lives in houses and cowsheds. In Israel, 30-60% of caves were found to be infested. PCR studies of Borrelia infection of O. tholozani ticks collected in caves showed very variable rates, ranging from less than 2% to 40%. The number of human cases reported varies among countries, from eight cases per year in Israel to 72 cases per year in Iran. The incubation period is 5-9 days. The fever attacks last from several hours to 4 days, and are accompanied by chills, headache, nausea and vomiting, sweating, abdominal pain, arthralgia, and cough; complications are rare. Other described Borrelia species are Borrelia caucasica, Borrelia latyschewii, Borrelia microtii, and Borrelia baltazardi. The classic taxonomy based on the co-speciation concept is very complex and very confusing. For this reason, 16S rRNA and flaB genes were used for taxonomic clarification. Sequencing of Israeli TBRF flaB genes, from human and tick samples, has demonstrated a third cluster corresponding to the Eurasia strains, in addition to both New World and Old World clusters. Thin and thick blood smears remain the most frequently used methods for laboratory diagnosis, with a sensitivity of 80%. PCR-based diagnosis is the most sensitive method, and has the advantage of allowing species identification.

[Laboratory methods for the diagnosis of clinical forms of Lyme borreliosis]. / Méthodes du diagnostic biologique au cours des différentes manifestations de la borréliose de Lyme.

Methods used to diagnose Lyme borreliosis (LB) vary according to clinical presentations. A very good basis to clarify this nosological and clinical entity is the study published by the "European Concerted Action on Lyme Borreliosis" (EUCALB). In fact, only few studies were performed on cohorts of patients including all clinical forms of LB. For Erythema migrans, serology sensitivity is low (20% to 50%), while the sensitivity of culture or PCR reaches 50%. In early-complicated forms, serology is more sensitive (70 to 90%) with the presence of concomitant IgG and IgM. Screening for antibodies in CSF is very useful for the diagnosis of neuroborreliosis. For this clinical form, culture or PCR sensitivity is disappointing (10 to 30%). In arthritis and acrodermatitis chronica atrophicans (ACA), IgG serology is 100% positive with very high titers; however IgM serology is only positive in 5 to 10% of the cases. In ACA, culture sensitivity ranges from 20 to 60% and PCR sensitivity from 60 to 90%. Specificity of antibodies, natural exposure to the etiologic agent, and cross-reactivity are critical for the final interpretation of serological assessment. Only the use of "serological profiles" allows the exploitation of detailed results (isotypes, intensity). In this approach, IgG avidity could be constructive. The western-blot is intended to confirm the specificity of antibodies found in screening methods (Elisa).

Full spectrum of clinical, serological, and epidemiological features of complicated forms of Lyme borreliosis in the Paris, France, area.

The aim of this study was to report the clinical, serological and epidemiological features of a homogeneous cohort of patients with various forms of Lyme borreliosis, based on recent European case-definition guidelines. Complete clinical and epidemiological reports were requested from the patients' physicians for case definition. Enzyme immunoassay IgG and IgM screening tests were performed. A total of 170 patients (141 adults and 29 children) with the following forms of Lyme borreliosis were included between 1989 and 1997: erythema migrans alone (n = 38), early neuroborreliosis (n = 76), arthritis (n = 34), acrodermatitis chronica atrophicans (n = 12), carditis (n = 2), lymphocytoma (n = 3), chronic neuroborreliosis (n = 2), and miscellaneous disorders (n = 3). On the basis of the occurrence and course of the full spectrum of complicated forms of Lyme borreliosis, the specificity of the clinical and biological presentation of the complicated forms (age, ratio of children/adults, sex ratio, incubation period, time to diagnosis, and serological profiles) was demonstrated, as was the absence of overlap between the clinical presentations. Using these data, an alternative scheme for the natural history of Lyme borreliosis is suggested.

Differentiation between early and late complicated Lyme borreliosis by specific IgG avidity.

Patients with early complicated forms of Lyme borreliosis had a low specific IgG avidity index and patients with late forms had a high avidity index. Naturally exposed individuals had intermediate values.

[Lyme borreliosis: therapeutic aspects]. / Borrélioses de Lyme: aspects thérapeutiques.

CAUSAL AGENTS: Several Borrelia burgdorferi sensu lato species have been recently described which cause different clinical forms of Lyme disease. B. garinii is implicated in neurological forms, B. burgdorferi sensu stricto in articular forms and B. afzelii in late cutaneous forms. As such disease diversity is seen only in Europe and Asia, clinical management in Europe is somewhat different than in North America. NUMEROUS CLINICAL TRIALS: A recently proposed classification of the European forms of Lyme disease is based on clinical presentation: contagious conditions or erythema migrans, early neurologic or cardiologic complications, late articular, neurologic or cutaneous complications. Therapeutic proposals should be guided by the results of European trials, taking into account this classification. ADAPTED MANAGEMENT: For contagious conditions or erythema migrans, amoxicillin and doxycycline are the first intention antibiotics and should be given for 14 to 21 days. Other antibiotic classes (macrolides, oral cephalosporins) have not been found be more effective and should be reserved for second line treatment. Early neurological involvement requires penicillin, a third generation cephalosporin or doxycycline for one month. Oral antibiotics are preferred in case of joint involvement using amoxicillin or doxycycline as first line therapy. A second regimen could be proposed in case of failure. Parenteral administration should be reserved for second line treatment. There is little data available on chronic atrophic acrodermatitis and protocols are based on ceftriaxone, doxycycline or penicillin.

Atypical Lyme borreliosis in an HIV-infected man.

We report the fourth case of Lyme borreliosis in a man infected with human immunodeficiency virus (HIV). The erythema chronicum migrans was persistent, overlapping with meningoradiculitis. Repeated immunofluorescence tests for Borrelia burgdorferi sensu lato remained negative in both sera and cerebrospinal fluid (CSF), the enzyme-linked immunosorbent assay was weakly positive in serum and CSF and a Western blot was positive. The skin infiltrate was composed mostly of T lymphocytes with a CD4/CD8 ratio of 0.5. The course of the disease was favourable after treatment with intravenous ceftriaxone. Further studies are necessary to evaluate whether HIV infection influences, as does syphilis, the course and response to treatment of Lyme borreliosis. Serological tests are insufficiently sensitive and the Western blot assay is necessary to confirm Lyme disease in HIV-positive patients.

Diversity of Borrelia burgdorferi sensu lato evidenced by restriction fragment length polymorphism of rrf (5S)-rrl (23S) intergenic spacer amplicons.

The organization of the ribosomal genes is unique in Borrelia burgdorferi in that the rrl (23S) and rrf (5S) genes are tandemly duplicated. We took advantage of this uniqueness to assess the restriction polymorphism of PCR products obtained with primers at the 3' end of the first rrf gene and at the 5' end of the second rrl gene. An amplicon that was 226 to 266 bp long was generated from 99 to 100 B. burgdorferi sensu lato strains. The nuclease MseI restriction polymorphism of the amplicons provided a useful tool for identifying B. burgdorferi sensu stricto, Borrelia garinii, Borrelia afzelii (formerly group VS461), and Borrelia japonica (formerly group F63B). Furthermore, it allowed us to recognize four new genomic groups, which were confirmed by DNA-DNA hybridization data. Two of these genomic groups comprised European strains, and the other two groups contained American strains. The American genomic groups involved vectors with enzootic cycles quite different from those of B. burgdorferi sensu stricto, which previously was the only Lyme disease Borrelia species known to occur in the United States. Our method could be used for rapid screening of strain collections and for epidemiological and medical purposes.

Individualisation of two new genomic groups among American Borrelia burgdorferi sensu lato strains.

We developed a quick typing method for Borrelia burgdorferi sensu lato strains using a fla gene-based PCR assay, followed by dot blot hybridization with non-radioactive species-specific probes. Thirty-six out of 46 strains belonged to one of the four described species (B. burgdorferi sensu stricto n = 11, B. garinii n = 11, B. afzelii n = 9 and B. japonica n = 5) and hybridized with its own species-specific probe. Among the 10 remaining American strains, two new additional genomic groups were identified. This finding was confirmed by direct sequencing of the fla gene-derived amplicons and whole DNA hybridization.

[Synergy between tobramycin and netilmicin on three strains of methicillin and gentamicin resistant staphylococci (S. epidermidis, S. aureus)]. / Synergie entre la tobramycine et la nétilmicine sur trois souches de staphylocoques méticilline et gentamicine résistants (S. epidermidis, S. aureus).

The antibacterial effect of tobramycin-netilmicin combination on multiresistant strains of staphylococcus was performed to determine the signification of synergy images on diffusion plates. Meticillin and gentamicin resistant strains of S. epidermidis (2 strains) and S. aureus (1 strain) were examined and showed an index of combined effect < 0.05 demonstrating synergy. These values were obtained with aminoglycoside concentrations < or = 4 mg/l, levels which can be considered as pharmacologically acceptable. This synergic action can be explained by specific inhibition of the resistance enzyme in the strains, possibly in combination with a cooperative effect on the classical targets of aminoglycosides. This type of combination using tobramycin and netilmicin could define a new use of aminoglycosides based on the conception of combining antibiotic enzyme inhibition.

Western blot analysis of sera from Lyme borreliosis patients according to the genomic species of the Borrelia strains used as antigens.

Sera of 52 Lyme borreliosis patients classified according to their clinical features were analysed by Western blot using as antigens Borrelia strains belonging to three recently described genomic species. The antibody response was demonstrated to be homologous within each genospecies. Serum reactivity was studied for each of the type strains Borrelia burgdorferi sensu stricto (strain B31T), Borrelia garinii (strain 20047T) and group VS461. Seven of 15 sera (46.6%) of patients with meningoradiculitis showed preferential reactivity with Borrelia garinii (strain 20047T), all of 8 sera (100%) of patients with acrodermatitis chronica atrophicans showed preferential reactivity with group VS461 (strain VS461) and 8 of 16 sera (50%) of patients with arthritis showed preferential reactivity with Borrelia burgdorferi sensu stricto (strain B31T). The presence of a strong response to OspA and OspB proteins of Borrelia burgdorferi sensu stricto was found only in this last group of patients. These results suggest that there are clinical implications of the recently described modifications in the taxonomy of Borrelia burgdorferi.