Burkholderia cepacia lower respiratory tract infection associated with exposure to a respiratory therapist.

OBJECTIVE: To investigate and control a nosocomial outbreak of Burkholderia cepacia lower respiratory tract infection. DESIGN: Outbreak investigation and case-control study. SETTING: A 260-bed community hospital. PATIENTS: Participants were mechanically ventilated intensive care patients without cystic fibrosis. A case was defined as a hospitalized patient with a sputum culture positive for B. cepacia between January 1 and November 6, 1998. METHODS: Respiratory therapy infection control policies and practices were reviewed; laboratory and environmental studies and a retrospective case-control study were conducted. Case-patients were matched with control-patients on age, gender, diagnosis, and type of intensive care unit. RESULTS: Nine case-patients were identified; B. cepacia likely caused pneumonia in seven and colonization in two. Two respiratory therapy practices probably contributed to the transmission of B. cepacia: multidose albuterol vials were used among several patients, and nebulizer assemblies often were not dried between uses. B. cepacia was grown from cultures of three previously opened multidose vials; pulsed-field gel electrophoresis patterns of B. cepacia from seven case-patients and two multidose vials were indistinguishable. Case-patients had longer durations of heated humidified mechanical ventilation (mean, 9.8 days vs 4.4 days; P=.03) and were more likely to have exposure to one particular respiratory therapist than controls (odds ratio, undefined; 95% confidence interval, 4.7-infinity; P=.001). The association with the respiratory therapist, a temporary employee, persisted after controlling for duration of heated humidified ventilation. No new B. cepacia infections were identified after control measures were implemented. CONCLUSIONS: B. cepacia probably was transmitted among patients through use of extrinsically contaminated multidose albuterol vials. Respiratory therapy departments must pay close attention to infection control practices, particularly among new or temporary staff.

A foodborne outbreak of Campylobacter jejuni (O:33) infection associated with tuna salad: a rare strain in an unusual vehicle.

We report a foodborne outbreak of Campylobacter jejuni infection in a summer camp. Outbreak-related cases occurred in 79 persons including 3 secondary cases in campers. Campylobacter jejuni was isolated from stool specimens from 16 of 21 patients who submitted a sample; 13 viable isolates were serotyped and all were serotype O:33 (somatic O scheme) or HL:18 (heat-labile scheme), and biotype III (Lior scheme). This serotype is widely distributed geographically but rarely isolated from humans. Samples of water from the wells supplying the camp were negative for faecal coliforms, and raw milk had not been served in the camp. A matched (1:1) case-control study identified tuna salad served for lunch on 19 July as the likely food item associated with illness (matched odds ratio=22; 95% confidence intervals (CI)=3.6-908). Swimming in the camp pool and other recreational water use in area lakes by the campers were not statistically associated with illness. The precise mechanism of introduction of the organism into the tuna salad remains unknown; contamination most likely occurred through cross-contamination with another food product, the hands of a food handler, or a work surface. Several deficiencies in the operation of the camp kitchen were identified. In Wisconsin, kitchens of such camps are subject to different inspection rules than restaurants. Camp staff, administrators, counselors, food managers, and infirmary staff, should fulfil important roles in their respective areas to prevent future outbreaks.

Incomplete sanitation of a meat grinder and ingestion of raw ground beef: contributing factors to a large outbreak of Salmonella typhimurium infection.

Consumers in the United States continue to eat raw or undercooked foods of animal origin despite public health warnings following several well-publicized outbreaks. We investigated an outbreak of Salmonella serotype Typhimurium infection in 158 patients in Wisconsin during the 1994 Christmas holiday period. To determine the vehicle and source of the outbreak, we conducted cohort and case-control studies, and environmental investigations in butcher shop A. Eating raw ground beef purchased from butcher shop A was the only item significantly associated with illness [cohort study: relative risk = 5.8, 95% confidence interval (CI) = 1.5-21.8; case control study: odds ratio = 46.2, 95% CI = 3.8-2751]. Inadequate cleaning and sanitization of the meat grinder in butcher shop A likely resulted in sustained contamination of ground beef during an 8-day interval. Consumer education, coupled with hazard reduction efforts at multiple stages in the food processing chain, will continue to play an important role in the control of foodborne illness.

Rapid susceptibility testing for nontuberculosis mycobacteria using flow cytometry.

We demonstrated previously that susceptibility testing of Mycobacterium tuberculosis could be accomplished within 24 h after the organisms were incubated with antituberculosis agents by using fluorescein diacetate (FDA) staining and flow cytometry. Continued studies have now shown that assay suspensions containing M. avium, M. fortuitum, M. gordonae, or M. marinum incubated with various concentrations of ciprofloxacin, clarithromycin, erythromycin, kanamycin, rifampin, tobramycin hydrolyzed less FDA than drug-free controls. Suspensions of treated and nontreated mycobacteria could be easily differentiated at 6 and 24 h after the initiation of the susceptibility assays by using FDA staining and flow cytometry. In addition, multiplication of the mycobacteria was not required to discern differences between drug-free suspensions of mycobacteria and those treated with antimycobacterial agents. The flow cytometric assay is simple, reproducible, and rapid.

Rapid susceptibility testing of Mycobacterium tuberculosis (H37Ra) by flow cytometry.

The resurgence of tuberculosis has caused considerable effort to be focused on the development of rapid methods for determining the susceptibility of Mycobacterium tuberculosis to antimycobacterial agents. We demonstrated that susceptibility testing of M. tuberculosis can be accomplished rapidly by using flow cytometry. Results of tests were available within 24 h after M. tuberculosis organisms were incubated with ethambutol, isoniazid, rifampin, or streptomycin. The method was based on the ability of viable M. tuberculosis organisms to hydrolyze fluorescein diacetate (FDA) and the detection of fluorescent mycobacteria by flow cytometric analysis. The assay system also did not require multiplication of the mycobacteria. In contrast, M. tuberculosis organisms exposed to antimycobacterial agents hydrolyzed significantly less FDA. The use of flow cytometry and FDA staining shows considerable promise as a rapid method for obtaining susceptibility test results.

Evaluation of C. diff.-CUBE test for detection of Clostridium difficile-associated diarrhea.

The toxin B assay was used to evaluate C. diff.-CUBE, a new dot-immunobinding assay (DIA) for the laboratory diagnosis of Clostridium difficile-associated diarrhea. The widely used latex agglutination test was also included for comparison. Stools from 100 patients suspected of having C. difficile-associated diarrhea were tested. The toxin B assay, latex agglutination, and DIA tests were positive for 12%, 9%, and 22% of the specimens, respectively. The sensitivity, specificity, and positive and negative predictive values of the DIA test were 67%, 84%, 36%, and 95%, respectively, compared with the toxin B assay. The specificity (98%) and positive predictive value (78%) for the latex agglutination test were significantly higher than those of the DIA test. Of 13 specimens solely positive by the DIA test, 11 were cultured and none were positive. Clinical assessment supported only two of the 13 positive DIA results. When clinical assessment was included in the analysis, the DIA positive predictive value rose to 45%. Although the sensitivity and negative predictive values of the DIA test are comparable to the latex agglutination test, the low specificity and positive predictive values of the DIA test make it an inappropriate method to use for screening in a population with a low prevalence of true positives.

Evaluation of two commercial procedures for rapid identification of Neisseria gonorrhoeae using a reference panel of antigenically diverse gonococci.

Two commercial tests for the rapid identification of Neisseria gonorrhoeae were evaluated. Two hundred seventy-nine organisms were tested, including 202 strains of N. gonorrhoeae. The Syva MicroTrak test results were less subjective but required a fluorescence microscope. The Phadebact Monoclonal GC OMNI Test required modification of the manufacturer's interpretive instructions in order to avoid cross-reactions, but it was a practical test. Specificities of both tests were 100%. Sensitivities of the Phadebact Monoclonal GC OMNI and Syva MicroTrak tests were 100% and approximately 100%, respectively.

Comparison of modified Bordet-Gengou and modified Regan-Lowe media for the isolation of Bordetella pertussis and Bordetella parapertussis.

Culture and fluorescent-antibody methods for detection of Bordetella species were evaluated by two state public health laboratories. Field-inoculated plates of Regan-Lowe agar medium were most useful if incubation was initiated on the day of collection. Regan-Lowe and Bordet-Gengou media were comparable for subculturing nasopharyngeal specimens that were transported and enriched in half-strength Regan-Lowe agar. Maximum sensitivity was achieved when the media were used in parallel. Fluorescent-antibody-stained smears of nasopharyngeal specimens were more sensitive for detection of Bordetella pertussis than for detection of Bordetella parapertussis. The fluorescent-antibody method, however, was too insensitive for use without culture.

Antimicrobial susceptibilities of Bordetella species isolated in a Multicenter Pertussis Surveillance Project.

MICs for 90% (MIC90s) of 75 Bordetella pertussis strains for amoxicillin, erythromycin, rifampin, and sulfamethoxazole-trimethoprim were 1, less than or equal to 0.12, 1, and 4 micrograms/ml, respectively. Susceptibility rates were all greater than or equal to 93%. Only 17% of the strains were susceptible to tetracycline. The MIC90s of ciprofloxacin, enoxacin, norfloxacin, ofloxacin, and roxithromycin were less than or equal to 0.06, 0.5, 0.25, 0.12, and 0.5 micrograms/ml, respectively. For B. parapertussis, the MIC90s were 16-fold higher with amoxicillin and rifampin and 2- to 4-fold higher with the fluoroquinolones and roxithromycin.

Predicting the susceptibility of anaerobes to cefoperazone, cefotaxime, and cefoxitin with the thioglycolate broth disk procedure.

A variety of clinical anaerobic isolates were tested against cefoperazone (216 strains), cefoxitin (120 strains), and cefotaxime (120 strains) by the thioglycolate anaerobic broth disk method, and the results were compared with the National Committee for Clinical Laboratory Standards reference agar dilution method. The broth disk and reference breakpoint concentrations were as follows: cefoperazone, 60 and 64 or 30 and 32 micrograms/ml; cefotaxime, 30 and 32 micrograms/ml; cefoxitin, 18 and 16 micrograms/ml, respectively. Discrepant results were retested to obtain a mode. There was 99% agreement between the broth disk and reference methods for cefotaxime, 98% for cefoperazone with 60- and 64-micrograms/ml breakpoints and 91% with 30- and 32-micrograms/ml breakpoints, and 75% for cefoxitin. All but one of the strains that produced false susceptibility results by broth disk were members of the Bacteroides fragilis group, 1 with cefoperazone using the 60-micrograms/ml concentration, 14 with cefoperazone at the 30-micrograms/ml concentration, and 27 with cefoxitin. One strain of Clostridium difficile produced false susceptibility results to cefoperazone at the 30-micrograms/ml concentration. The lack of agreement between the broth disk and reference methods with cefoxitin may be a reflection of the number of isolates at the 16-micrograms/ml level and that the broth disk breakpoint was slightly higher than this concentration. Increased incubation time did not improve the results significantly.

Evaluation of the 10-micrograms clindamycin disk for susceptibility testing of anaerobes by the aerobically incubated thioglycolate broth disk method.

The reliability of the 10-micrograms clindamycin disk was evaluated for susceptibility testing of anaerobes by the aerobic thioglycolate broth disk method. A good correlation between the aerobic thioglycolate broth disk method and the reference agar dilution procedure of the National Committee for Clinical Laboratory Standards was obtained by using a 4-microgram/ml breakpoint. Improved correlation was obtained when the medium of the National Committee for Clinical Laboratory Standards was buffered.

Antimicrobial activity of cefmetazole compared with those of other cephalosporins.

The antimicrobial activity of cefmetazole was compared with those of cefmenoxime, ceftizoxime, cefamandole, cefoperazone, cefotaxime, cephalothin, and latamoxef. In general, the activity of cefmetazole was less than those of the other cephalosporins. The in vitro activity of cefmetazole suggests that it will not prove useful as a broad-spectrum antimicrobial against gram-positive and gram-negative pathogens.

Evaluation of the phadebact and bactigen reagents for detection of Neisseria meningitidis in cerebrospinal fluid.

The Phadebact and Bactigen reagents were evaluated for detection of Neisseria meningitidis in cerebrospinal fluids. The Bactigen test yielded stronger agglutination reactions from clinical specimens and was significantly more sensitive when used with whole-cell suspensions and purified antigens.

Evaluation of three commercial agglutination tests for the identification of Staphylococcus aureus.

Three commercially available rapid slide agglutination tests for the identification of Staphylococcus aureus were evaluated with 354 recent clinical isolates (165 strains of S. aureus). The test results of two latex agglutination products, SeroSTAT Staph (Scott Laboratories, Inc.) and Staphylatex (American Micro Scan), and one hemagglutination product, Staphyloslide (BBL Microbiology Systems), were compared with the results of the tube coagulase test, which was read at 4 h (4-h tube coagulase test) and, if negative, again after overnight incubation at room temperature (24-h tube coagulase test). Discrepancies between agglutination and tube coagulase identifications were resolved by use of the thermonuclease, mannitol fermentation, and slide coagulase tests. All sensitivities, specificities, predictive values of a positive result, and predictive values of a negative result for the three agglutination tests were at least 98.8% and comparable with the 4-h tube coagulase test. Best results were obtained with the 24-h tube coagulase test, which yielded one false-negative and no false-positive tests. Agglutination identifications may be performed on organisms taken directly from a primary plate when sufficient growth is present. Kit agglutination procedures yield rapid and reliable identifications and are easy to perform. This study also demonstrates the usefulness of the 24-h tube coagulase test.

Evaluation of two broth disk methods for antibiotic susceptibility testing of anaerobes.

We evaluated the aerobic thioglycolate broth disk and the vaspar overlay broth disk methods for antibiotic susceptibility testing of 144 strains of anaerobes. For penicillin, carbenicillin, chloramphenicol, and metrionidazale, both broth disk methods yielded at least 95% agreement with results obtained by the National Committee for Clinical Laboratory Standards reference agar dilution procedure. For cefoxitin and clindamycin, the agreement was ca. 90%. Overall, the aerobic thioglycolate broth disk and vaspar overlay broth disk methods yielded agreements of 93.3 and 93%, respectively, with the National Committee for Clinical Laboratory Standards method.

The use of CIE for the detection of Clostridium difficile toxin in stool filtrates: laboratory and clinical correlation.

Two CIE procedures (CIE-1, CIE-2) for the detection of Clostridium difficile in diarrheal stools were evaluated by comparison to cytotoxin assay and culture results and by comparison to a clinical likelihood of C. difficile-induced diarrhea. Using a combination of toxin assay and culture results for reference, the CIE-1 and CIE-2 procedures had sensitivities of 33% and 47%, specificities of 89% and 91%, and positive predictive values of 42% and 54%, respectively. Using clinical likelihood for reference, the best results were obtained by the CIE-2 method, which yielded a positive predictive value of 77%. Neither CIE procedure provided an acceptable sensitivity for the detection of C. difficile in stools.

In vitro susceptibility of Clostridium difficile isolates to cefotaxime, moxalactam, and cefoperazone.

The in vitro susceptibility of 20 isolates of Clostridium difficile to cefotaxime, moxalactam, and cefoperazone was determined by a standard agar dilution method. The median minimal inhibitory concentrations were 64, 32, and 32 mug/ml for cefotaxime, moxalactam, and cefoperazone, respectively.

Evaluation of techniques for isolation of group A streptococci from throat cultures.

In the first study, selective sulfamethoxazole-trimethoprim blood agar (SXT-BA) and conventional blood agar (BA) plates incubated under CO2 and anaerobically were compared for their ability to recover group A streptococci from throat cultures. Recovery rates were: SXT-BA (anaerobic), 100%; SXT-BA (CO2), 98%; BA (anaerobic), 89.2%; and BA (CO2), 76.5%. Primary plate bacitracin test results could be read on significantly more of the SXT-BA plates. Readability rates were: SXT-BA (anaerobic), 97%; SXT-BA (CO2), 96%; BA (anaerobic), 70.6%; and BA (CO2), 32.4%. A second study compared with the SXT-BA method versus a BA-double-disk (BA-DD) method which utilizes conventional media with addition of a bacitracin differentiation and a sulfamethoxazole-trimethoprim susceptibility disk placed adjacent to one another in the heavy area of inoculation. Isolation rates were: SXT-BA, 100% and BA-DD, 88%. Readability rates for direct bacitracin tests were: SXT-BA, 92% and BA-DD, 76.2%. In our hands, the SXT-BA method was superior for yielding highest isolation rates and for yielding highest readability rates of direct bacitracin test results.