Reduced vancomycin susceptibility and increased macrophage survival in Staphylococcus aureus strains sequentially isolated from a bacteraemic patient during a short course of antibiotic therapy.

PURPOSE: The purpose of the present study was to determine the relatedness of Staphylococcus aureus strains successively isolated over a 7-day period from a single bacteraemic patient undergoing antibiotic treatment with vancomycin. METHODS: The S. aureus strains had been isolated and sequenced previously. Antibiotic susceptibility testing, population analysis profiling, and lysostaphin sensitivity and phagocytic killing assays were used to characterize these clonal isolates. RESULTS: The seven isolates (MEH1-MEH7) were determined to belong to a common multilocus sequence type (MLST) and spa type. Within the third and fifth day of vancomycin treatment, mutations were observed in the vraS and rpsU genes, respectively. Population analysis profiles revealed that the initial isolate (MEH1) was vancomycin-susceptible S. aureus (VSSA), while those isolated on day 7 were mostly heteroresistant vancomycin-intermediate S. aureus (hVISA). Supporting these findings, MEH7 was also observed to be slower in growth, to have an increase in cell wall width and to have reduced sensitivity to lysostaphin, all characteristics of VISA and hVISA strains. In addition, MEH7, although phagocytosed at numbers comparable to the initial isolate, MEH1, survived in higher numbers in RAW 264.7 macrophages. Macrophages infected with MEH7 also released more TNF-α and IFN-1ß. CONCLUSION: We report an increasing resistance to vancomycin coupled with daptomycin that occurred within approximately 3 days of receiving vancomycin and steadily increased until the infection was cleared with an alternative antibiotic therapy. This study reiterates the need for rapid, efficient and accurate detection of hVISA and VISA infections, especially in high-bacterial load, metastatic infections like bacteraemia.

Draft Genome Sequences of Two Staphylococcus aureus Strains Isolated in Succession from a Case of Bacteremia.

Staphylococcus aureus strains MEH1 and MEH7 were successively isolated from the blood of a patient with recurrent bacteremia. The submitted draft genomes of strains MEH1 and MEH7 are 2,914,972 and 2,911,704 bp, respectively.

Integral role of interventional radiology in the development of a pediatric liver transplantation program.

The aim of this study was to examine the role of interventional radiology (IR) in the pretransplant evaluation of potential living-related liver transplantation (LRLT) donors and in the post-transplant management of pediatric liver transplant recipients. Medical records and procedural reports were reviewed of 12 potential donors and five recipients for left lateral segment liver transplants. Procedures performed by the IR Division, clinical indications, and complications were tabulated. Retrospective calculation of radiation exposure to the skin and gonads of the donors and recipients were made. Three-dimensional ultrasound (3D US) was used in all 12 potential donors to screen for the donor with the most appropriately sized left lateral segment. The four optimal donor candidates underwent contrast angiography in order to measure the diameter and screen for variant arterial supply to the left lateral segment. Pretransplantation, one recipient underwent mesenteric angiography with indirect portography to confirm thrombosis of the portal vein and to prove patency of the splenomesenteric venous confluence. Three children underwent LRLT and two children received split livers from cadaveric donors. Thirty-two IR procedures were performed after transplantation (Tx) in the four transplant survivors (one child died following Tx). These IR procedures included: ultrasound-guided percutaneous liver biopsy to evaluate the pathologic cause of liver dysfunction (seven); placement of nasal jejunal feeding tubes (three) or a peripherally inserted central catheter (four) for nutritional and pharmacologic support; large-volume diagnostic and therapeutic paracentesis (two) and thoracentesis (one); percutaneous catheter drainage of symptomatic large pleural effusions (two), large-volume chylous ascites (one) (with later drain removal [one]), and a large biloma (one); percutaneous biliary drain placement (three), biliary drain replacement (two), and balloon cholangioplasty (four) to relieve obstructive jaundice from biliary enteric anatomic strictures; and mesenteric arteriography (one) for suspected thrombosis of the hepatic artery. No complications occurred. Mean skin and gonadal radiation doses were 193 mGy and 27 mGy, respectively, for donors, and 164 mGy and 60 mGy, respectively, for recipients. Even in a program such as this, with a limited series of pediatric liver Txs, it is apparent that IR plays an integral role in optimizing the clinical outcome and use of resources. Specific benefits included: selection of optimal donors; accurate mapping of the donor and occasionally recipient hepatic vasculature; and, most importantly, providing relatively safe minimally invasive procedures for nutritional support and diagnosis and management of untoward events after Tx. When possible, ultrasound guidance should be used to avoid excessive cumulative fluoroscopic exposure to recipients.

Isolation of stable hemolysin and catalase variants of Staphylococcus aureus S6C includes one with an exoprotein-deficient phenotype.

Previous studies suggested that the exoprotein-deficient phenotype of a Delta 1058::Tn551 insertion/deletion mutant of Staphylococcus aureus S6C was not owing to the insertion/deletion event, but instead was owing to the inherent instability of the agrC gene during transduction of the Delta 1058::Tn551 region into S6C. The purpose of the following study was to examine S6C as a potential source of exoprotein-deficient mutants that would account for their appearance after transposition and transduction. Four stable variants of S6C were isolated that differed in their hemolysin and catalase activities. Surprisingly, the agr regulatory molecule, RNAIII, was undetectable in one of these variants, which most likely accounted for the exoprotein-deficient phenotype of this variant. When the original Delta 1058::Tn551 mutation was transduced into the hemolytic, catalase-positive variant of S6C, none of the transductants exhibited an exoprotein-deficient phenotype. These data suggest that, while the exoprotein-deficient phenotype of the S6C variant is most likely due to mutations in the agr regulatory system, these mutations are not caused by the transduction of the Delta 1058::Tn551 region into S6C, but instead already exist in an exoprotein-deficient variant of S6C.

Identification and characterization of a second superoxide dismutase gene (sodM) from Staphylococcus aureus.

A gene encoding superoxide dismutase (SOD), sodM, from S. aureus was cloned and characterized. The deduced amino acid sequence specifies a 187-amino-acid protein with 75% identity to the S. aureus SodA protein. Amino acid sequence comparisons with known SODs and relative insensitivity to hydrogen peroxide and potassium cyanide indicate that SodM most likely uses manganese (Mn) as a cofactor. The sodM gene expressed from a plasmid rescued an Escherichia coli double mutant (sodA sodB) under conditions that are otherwise lethal. SOD activity gels of S. aureus RN6390 whole-cell lysates revealed three closely migrating bands of activity. The two upper bands were absent in a sodM mutant, while the two lower bands were absent in a sodA mutant. Thus, the middle band of activity most likely represents a SodM-SodA hybrid protein. All three bands of activity increased as highly aerated cultures entered the late exponential phase of growth, SodM more so than SodA. Viability of the sodA and sodM sodA mutants but not the sodM mutant was drastically reduced under oxidative stress conditions generated by methyl viologen (MV) added during the early exponential phase of growth. However, only the viability of the sodM sodA mutant was reduced when MV was added during the late exponential and stationary phases of growth. These data indicate that while SodA may be the major SOD activity in S. aureus throughout all stages of growth, SodM, under oxidative stress, becomes a major source of activity during the late exponential and stationary phases of growth such that viability and growth of an S. aureus sodA mutant are maintained.

Adjunctive 3D US for achieving portal vein access during transjugular intrahepatic portosystemic shunt procedures.

PURPOSE: To evaluate the usefulness of information provided by three-dimensional ultrasound (3D US) and to determine whether 3D US decreased the number of passes required to obtain portal vein (PV) access during creation of transjugular intrahepatic portosystemic shunts (TIPS). MATERIALS AND METHODS: Intermittent 3D US volume acquisitions were obtained during creation of TIPS in 20 patients. Useful information provided by 3D US was tabulated. The number of passes required to achieve PV access was recorded and results were compared retrospectively to 25 patients who underwent TIPS without 3D US. RESULTS: 3D US documented that the operator's opinion of which hepatic vein had been selected was incorrect in nine patients (45%), detected unfavorable PV anatomy that required modification of equipment or technique in seven patients (35%), permitted estimation of the trajectory required to access the targeted PV in all patients (100%), assisted in selecting the optimal point along the hepatic vein for origination of the needle pass in 11 patients (55%), allowed avoidance of a large hepatocellular carcinoma in one patient (5%), and confirmed that access into the main PV was intrahepatic in four patients (20%). The mean number of needle passes decreased from 10.4 in the historic control group to 4.6 in the 3D US group (P = .0001). CONCLUSION: 3D US provided imaging information that detected technical errors and altered anatomy, and provided positional and directional information to significantly improve needle pass efficiency.

Adjunctive 3D US for achieving portal vein access during transjugular intrahepatic portosystemic shunt procedures.

PURPOSE: To evaluate the usefulness of information provided by three-dimensional ultrasound (3D US) and to determine whether 3D US decreased the number of passes required to obtain portal vein (PV) access during creation of transjugular intrahepatic portosystemic shunts (TIPS). MATERIALS AND METHODS: Intermittent 3D US volume acquisitions were obtained during creation of TIPS in 20 patients. Useful information provided by 3D US was tabulated. The number of passes required to achieve PV access was recorded and results were compared retrospectively to 25 patients who underwent TIPS without 3D US. RESULTS: 3D US documented that the operator's opinion of which hepatic vein had been selected was incorrect in nine patients (45%), detected unfavorable PV anatomy that required modification of equipment or technique in seven patients (35%), permitted estimation of the trajectory required to access the targeted PV in all patients (100%), assisted in selecting the optimal point along the hepatic vein for origination of the needle pass in 11 patients (55%), allowed avoidance of a large hepatocellular carcinoma in one patient (5%), and confirmed that access into the main PV was intrahepatic in four patients (20%). The mean number of needle passes decreased from 10.4 in the historic control group to 4.6 in the 3D US group (P = .0001). CONCLUSION: 3D US provided imaging information that detected technical errors and altered anatomy, and provided positional and directional information to significantly improve needle pass efficiency.

Phylogenetic distribution of the global regulatory gene csrA among eubacteria.

The gene csrA encodes a unique kind of global regulator, CsrA, which modulates glycolysis, gluconeogenesis, glycogen biosynthesis and glycogen catabolism in Escherichia coli. Southern hybridization and nucleotide sequencing data have revealed apparent csrA homologs within several families of the alpha and gamma subdivisions of the proteobacteria (purple bacteria) and in the Gram-positive bacterium Bacillus subtilis. Thus, the CsrA regulatory system appears widely distributed among eubacteria.

Differential RNA regulation by staphylococcal enterotoxins A and B in murine macrophages.

Staphylococcal enterotoxin A (SEA) is significantly better than enterotoxin B (SEB) in activating tumor necrosis factor (TNF) secretion by B6MP102 cells. Both toxins bound to B6MP102 cells; however, SEB competed less effectively with SEA than SEA competed with SEB. This suggested that receptors unique to SEA were present on B6MP102 cells. Signal transduction occurred in response to both toxins. Within 30 s after addition, SEA and SEB significantly increased the F-actin concentration in B6MP102 cells. However, only SEA induced increased TNF mRNA levels. B6MP102 cells incubated with interferon-gamma and SEB secreted TNF. However, enhanced mRNA expression was delayed and the concentration of TNF secreted was less than that of B6MP102 cells stimulated with SEA. Although these data suggest that receptors unique to SEA are present on B6MP102 cells, they also indicate that staphylococcal enterotoxins differentially regulate TNF at the RNA level, perhaps because of differences in binding to the plasma membrane.

The effect of lysogeny on the genomic organization of Staphylococcus aureus.

The genome of Staphylococcus aureus strain S6C was shown to contain a prophage inserted within the beta-toxin (BT)-encoding structural gene (hlb). The phage att site was identical to that reported for the BT-converting phages phi 13 and phi 42. The prophage carried the genes encoding staphylokinase (sak) and enterotoxin A (sea), which suggests that it is similar to phi 42. However, it was not included in the presence of mitomycin C (MC) and appears to be defective. Mapping studies revealed that the genomes of the BT-converting phages present in strains S6C and PS42D (a phi 42 lysogen) encode at least one SmaI restriction site. Moreover, the PS42D chromosome contained a second prophage that also had at least one SmaI site, carried both sak and sea, and hybridized with DNA probes that also hybridize with the BT-converting phages. The second phage in strain PS42D was mapped to a SmaI fragment corresponding to fragment A of the S. aureus strain 8325 genomic map. Although the BT-converting phage present in strain S6C could not be induced, a phage was induced from strain S6C using MC. Southern blots suggest that is is similar to phi 11; however, the restriction patterns of DNA from the induced phage and phi 11 were clearly distinct. We have designated the inducible phage present in strain S6C as phi 15, to denote the distinction. Relatively weak hybridization signals were also observed when phi 15 DNA was used to probe genomic DNA from S. aureus strains lysogenized with the BT-converting phages, phi 13, phi 42 and 42E.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation and control of worker exposure to fungi in a beet sugar refinery.

A study of worker exposure to airborne fungi was undertaken in a sugar beet refinery to evaluate the level of exposure and to determine if controls could be implemented that would lower these exposures. A previous study at this refinery identified one worker who reacted on challenge testing to the moldy but not the fresh sugar beet pulp, had specific Immunoglobulin G to Aspergillus niger, and specific Immunoglobulin E to Aspergillus. Also, two employees were diagnosed with occupational asthma. In the study reported here, two field surveys were conducted, the first during the sugar production campaign (January) and the second during postproduction cleanup and maintenance (June). Approximately 65 personal and area air samples were collected on polycarbonate filters and the culturable fungal spores were identified and enumerated. This study showed high exposure of pellet loaders and pellet silo workers to various species of Aspergillus. Other fungal species that might pose a health hazard were detected. Exposures to fungi during the postproduction cleanup and maintenance phase were much higher than those measured during the production campaign. Engineering controls that would reduce employee exposure are discussed.

The extracellular protein regulator (xpr) affects exoprotein and agr mRNA levels in Staphylococcus aureus.

xpr, a regulatory element of exoprotein synthesis in Staphylococcus aureus, defined by an insertion of Tn551 into the chromosome of strain S6C, affects the expression of several exoproteins at the mRNA level. Drastic reduction in transcript levels for staphylococcal enterotoxin B (seb), lipase (geh), alpha-toxin (hla), and delta-toxin (hld) were detected, while mRNA levels for coagulase (coa) and protein A (spa) were elevated. Because the delta-toxin gene resides within the RNAIII transcript of the exoprotein regulator, agr, the reduction in hld message in the mutant strain of S6C is indicative of additional regulatory events in exoprotein gene expression. Northern (RNA) analysis of total cellular RNA hybridized with probes specific for RNAII and RNAIII (the two major transcripts of the agr operon) showed that both transcripts were reduced 16- to 32-fold at 3 h (late exponential phase) and 8- to 16-fold at 12 h (postexponential phase). These data confirm our original findings (M. S. Smeltzer, M. E. Hart, and J. J. Iandolo, Infect. Immun. 61:919-925, 1993) that two regulatory loci, agr and xpr, are interactive at the genotypic level.

Phenotypic characterization of xpr, a global regulator of extracellular virulence factors in Staphylococcus aureus.

We recently described a Tn551 insertion in the chromosome of Staphylococcus aureus S6C that resulted in drastically reduced expression of extracellular lipase (M. S. Smeltzer, S. R. Gill, and J. J. Iandolo, J. Bacteriol. 174:4000-4006, 1992). The insertion was localized to a chromosomal site (designated omega 1058) distinct from the lipase structural gene (geh) and the accessory gene regulator (agr), both of which were structurally intact in the lipase-negative (Lip-) mutants. In this report, we describe a phenotypic comparison between strains S6C, a hyperproducer of enterotoxin B; KSI9051, a derivative of S6C carrying the Tn551 insertion at omega 1058; ISP546, an 8325-4 strain that carries a Tn551 insertion in the agr locus; and ISP479C, the parent strain of ISP546 cured of the Tn551 delivery plasmid pI258repA36. Compared with their respective parent strains, ISP546 and KSI9051 produced greatly reduced amounts of lipase, alpha-toxin, delta-toxin, protease, and nuclease. KSI9051 also produced reduced amounts of staphylococcal enterotoxin B. Coagulase production was increased in ISP546 but not in KSI9051. Using a mouse model, we also demonstrated that ISP546 and KSI9051 were far less virulent than ISP479C and S6C. We have designated the genetic element defined by the Tn551 insertion at omega 1058 xpr to denote its role as a regulator of extracellular protein synthesis. We conclude that xpr and agr are similar and possibly interactive regulatory genes that play an important role in pathogenesis of staphylococcal disease.

Quantitative spectrophotometric assay for staphylococcal lipase.

We report the development of a specific spectrophotometric assay for the quantitative determination of lipase activity in Staphylococcus aureus. The assay is based on the rate of clearance of a tributyrin emulsion, and it can detect as little as 1.0 micrograms of purified Pseudomonas lipase per ml. By comparison with the reaction rates obtained with Pseudomonas lipase, we calculated that S. aureus PS54C and S6C produce approximately 15 and 60 micrograms of extracellular lipase per ml, respectively. Neither PS54, which is lysogenized with the converting bacteriophage L54a and is consequently lipase negative (Lip-), nor KS1905, a Lip- transpositional mutant of strain S6C, was positive in our spectrophotometric assay. The specificity of the spectrophotometric tributyrin assay was confirmed with a triolein plate assay; supernatants from S6C and PS54C hydrolyzed triolein, while supernatants from PS54 and KSI905 did not. In contrast to the results of the spectrophotometric tributyrin assay, all enzyme preparations tested (including commercially purified esterase) were positive when examined by a tributyrin plate assay. The lack of specificity in the tributyrin plate assay emphasizes the need to interpret the results of tributyrin lipolysis kinetically for assessing lipase activity in S. aureus.

Central venous catheterization in patients with coagulopathy.

To explore the risk of bleeding complications during percutaneous central venous catheterization in patients with coagulopathy, 40 liver transplant recipients underwent 259 percutaneous central venous catheterizations. Two hundred two catheterizations were performed in patients with coagulopathy, as evidenced by their prothrombin times, activated partial thromboplastin times, and/or platelet counts. Furthermore, no attempt was made to correct these episodes of coagulopathy with medications or infusion of blood products. No serious bleeding complications occurred during the 259 catheterizations, which suggests that experienced clinicians using appropriate techniques may safely perform central venous catheterization in patients with abnormal prothrombin times, activated partial thromboplastin times, and platelet counts.

Susceptibility to hydrophobic molecules and phospholipid composition in Pasteurella multocida and Actinobacillus lignieresii.

Despite its typically gram-negative cell envelope ultrastructure, Pasteurella multocida is susceptible to the hydrophobic antibiotic novobiocin and is unable to initiate growth on MacConkey agar, a parameter often used to effect is differentiation from other members of the family Pasteurellaceae such as Actinobacillus lignieresii. However, growth on basal medium supplemented with individual selective factors and an agar diffusion assay revealed the bile salts contained in MacConkey agar to be toxic to both organisms. Four P. multocida surface hydrophobicity variants exhibited consistent in vitro susceptibility to the hydrophobic antibiotics novobiocin, rifamycin SV, and actinomycin D as determined by broth dilution. Readily extractable lipid fractions were obtained by chloroform-methanol extraction of freeze-dried whole cells from exponential-phase cultures. No major differences in total cellular readily extractable lipid content were observed among the P. multocida and A. lignieresii strains examined, although hydrophobic P. multocida strains appeared to contain slightly more than did hydrophilic strains. Analytical thin-layer chromatography and quantitation of resolved readily extractable lipid components revealed the major cell envelope phospholipids of both organisms to be phosphatidylethanolamine and phosphatidylglycerol in a molar ratio of approximately 4:1 regardless of cell surface hydrophobicity properties. Similar results were obtained for Pseudomonas aeruginosa, which is notably refractory to hydrophobic molecules. These data support the conclusion that the permeability of the P. multocida cell envelope to structurally unrelated, hydrophobic molecules is not dependent on cell surface hydrophobicity and cannot be explained on the basis of anomalous polar lipid composition.

Low propensity for poultry isolates of Pasteurella multocida to acquire adaptive resistance to oxytetracycline.

Thirty independently derived reference strains and clinical isolates of Pasteurella multocida were tested to determine their potential for acquiring adaptive resistance to oxytetracycline in an effort to better understand the prolonged high efficacy of the antibiotic for pasteurellosis in poultry. All reference strains and clinical isolates exhibited uniform susceptibility as measured with the broth dilution method. None of the strains or isolates readily acquired significant resistance when grown in subinhibitory oxytetracycline levels under the conditions employed. These data support the conclusions that spontaneous variation in P. multocida resulting in oxytetracycline resistance is uncommon in the field and that the organism possesses a very low propensity for acquiring adaptive resistance in response to growth in the presence of the antibiotic.

Variability of cell surface hydrophobicity among Pasteurella multocida somatic serotype and Actinobacillus lignieresii strains.

Pasteurella multocida possesses a characteristically gram-negative ultrastructure, yet its inability to grow in the presence of hydrophobic compounds and the general penicillin susceptibility of genera making up the family Pasteurellaceae suggest a cell envelope having atypical permeability properties. The cell surface hydrophobicity properties of strains representing 15 of the 16 somatic serotypes of P. multocida and three strains of Actinobacillus lignieresii were assessed with hydrocarbon adherence and hydrophobic interaction chromatographic assays. These methods revealed surface hydrophobicity to vary dramatically among strains in both species. No direct correlation was observed with species, growth rate, or susceptibility to the antibiotics oxytetracycline (polar), polymyxin B (amphiphilic), or novobiocin (nonpolar) as measured with MIC determinations. All strains were susceptible to the antibiotics, although A. lignieresii was significantly less susceptible than P. multocida to novobiocin. These data suggest that cell surface hydrophobicity in P. multocida may be influenced by the type of lipopolysaccharide present but is not directly related to permeability of the antibiotics examined. The wide diversity of hydrophobic properties exhibited by strains of both P. multocida and A. lignieresii precludes the use of this parameter as a taxonomic acid.