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Volume 11, Number 10—October 2005

Volume 11, Number 10—October 2005   PDF Version [PDF - 6.12 MB - 159 pages]

Perspective

  • Antimicrobial Drug Resistance: "Prediction Is Very Difficult, Especially about the Future" PDF Version [PDF - 93 KB - 4 pages]
    P. Courvalin
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    Although resistance cannot be prevented, much can be done to delay it.

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    Evolution of bacteria towards resistance to antimicrobial drugs, including multidrug resistance, is unavoidable because it represents a particular aspect of the general evolution of bacteria that is unstoppable. Therefore, the only means of dealing with this situation is to delay the emergence and subsequent dissemination of resistant bacteria or resistance genes. Resistance to antimicrobial drugs in bacteria can result from mutations in housekeeping structural or regulatory genes. Alternatively, resistance can result from the horizontal acquisition of foreign genetic information. The 2 phenomena are not mutually exclusive and can be associated in the emergence and more efficient spread of resistance. This review discusses the predictable future of the relationship between antimicrobial drugs and bacteria.

  • Emerging Foodborne Trematodiasis PDF Version [PDF - 231 KB - 8 pages]
    J. Keiser and J. Utzinger
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    Foodborne trematodiasis is emerging because of increased aquaculture.

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    Foodborne trematodiasis is an emerging public health problem, particularly in Southeast Asia and the Western Pacific region. We summarize the complex life cycle of foodborne trematodes and discuss its contextual determinants. Currently, 601.0, 293.8, 91.1, and 79.8 million people are at risk for infection with Clonorchis sinensis, Paragonimus spp., Fasciola spp., and Opisthorchis spp., respectively. The relationship between diseases caused by trematodes and proximity of human habitation to suitable freshwater bodies is examined. Residents living near freshwater bodies have a 2.15-fold higher risk (95% confidence interval 1.38–3.36) for infections than persons living farther from the water. Exponential growth of aquaculture may be the most important risk factor for the emergence of foodborne trematodiasis. This is supported by reviewing aquaculture development in countries endemic for foodborne trematodiasis over the past 10–50 years. Future and sustainable control of foodborne trematodiasis is discussed.

Research

  • Evolution of H5N1 Avian Influenza Viruses in Asia PDF Version [PDF - 307 KB - 7 pages]
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    Human infections were from a virus clade undergoing antigenic drift that showed resistance to adamantanes but sensitivity to neuraminidase inhibitors.

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    An outbreak of highly pathogenic avian influenza A (H5N1) has recently spread to poultry in 9 Asian countries. H5N1 infections have caused >52 human deaths in Vietnam, Thailand, and Cambodia from January 2004 to April 2005. Genomic analyses of H5N1 isolates from birds and humans showed 2 distinct clades with a nonoverlapping geographic distribution. All the viral genes were of avian influenza origin, which indicates absence of reassortment with human influenza viruses. All human H5N1 isolates tested belonged to a single clade and were resistant to the adamantane drugs but sensitive to neuraminidase inhibitors. Most H5N1 isolates from humans were antigenically homogeneous and distinct from avian viruses circulating before the end of 2003. Some 2005 isolates showed evidence of antigenic drift. An updated nonpathogenic H5N1 reference virus, lacking the polybasic cleavage site in the hemagglutinin gene, was produced by reverse genetics in anticipation of the possible need to vaccinate humans.

  • New Measles Genotype, Uganda PDF Version [PDF - 203 KB - 5 pages]
    A. Muwonge et al.
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    New measles virus genotype will increase epidemiologic and virologic surveillance in Africa.

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    We report the first genetic characterization of wildtype measles viruses from Uganda. Thirty-six virus isolates from outbreaks in 6 districts were analyzed from 2000 to 2002. Analyses of sequences of the nucleoprotein (N) and hemagglutinin (H) genes showed that the Ugandan isolates were all closely related, and phylogenetic analysis indicated that these viruses were members of a unique group within clade D. Sequences of the Ugandan viruses were not closely related to any of the World Health Organization reference sequences representing the 22 currently recognized genotypes. The minimum nucleotide divergence between the Ugandan viruses and the most closely related reference strain, genotype D2, was 3.1% for the N gene and 2.6% for the H gene. Therefore, Ugandan viruses should be considered a new, proposed genotype (d10). This new sequence information will expand the utility of molecular epidemiologic techniques for describing measles transmission patterns in eastern Africa.

  • Pyrosequencing Bacillus anthracis PDF Version [PDF - 251 KB - 5 pages]
    T. Wahab et al.
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    Pyrosequencing technology was used to rapidly and specifically identify Bacillus anthracis.

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    Pyrosequencing technology is a sequencing method that screens DNA nucleotide incorporation in real time. A set of coupled enzymatic reactions, together with bioluminescence, detects incorporated nucleotides in the form of light pulses, which produces a profile of characteristic peaks in a pyrogram. We used this technology to identify the warfare agent Bacillus anthracis by sequencing 4 single nucleotide polymorphisms (SNPs) in the rpoB gene as chromosomal markers for B. anthracis. In addition, 1 segment in each of the B. anthracis plasmids pXO1 and pXO2 was analyzed to determine the virulence status of the bacterial strains. Pyrosequencing technology is a powerful method to identify B. anthracis.

  • Community-associated Methicillin-resistant Staphylococcus aureus, Minnesota, 2000–2003 PDF Version [PDF - 131 KB - 7 pages]
    J. M. Buck et al.
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    Community-associated methicillin-resistant Staphylococcus aureus (MRSA) invasive disease resembled healthcare-associated MRSA disease.

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    We compared characteristics of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) skin and soft tissue infections (SSTIs) and CA-MRSA invasive disease identified in Minnesota from 2000 through 2003. A total of 586 patients with SSTIs and 65 patients with invasive disease were identified. Patients with invasive disease were more likely to be smokers (p = 0.03), and report a history of immunosuppressive therapy (p = 0.03), emphysema (p = 0.011), or injection drug use (p = 0.020) than were SSTI patients. Invasive disease isolates were less likely to be susceptible to ciprofloxacin (p = 0.002) and clindamycin (p = 0.001) and more likely to have healthcare-associated pulsed-field gel electrophoresis subtypes than SSTI isolates (p<0.001). Patients with invasive disease may have had healthcare exposures that put them at risk of acquiring healthcare-associated MRSA and which were not exclusion criteria in the CA-MRSA case definition. Continued surveillance of MRSA is needed to better characterize CA-MRSA infections.

  • Methicillin-resistant Staphylococcus aureus and Vancomycin-resistant Enterococci Co-colonization PDF Version [PDF - 163 KB - 6 pages]
    J. P. Furuno et al.
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    High prevalence of co-colonization increases risk for colonization or infection by vancomycin-resistant Staphylococcus aureus.

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    We assessed the prevalence, risk factors, and clinical outcomes of patients co-colonized with vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) upon admission to the medical and surgical intensive care units (ICUs) of a tertiary-care facility between January 1, 2002, and December 31, 2003. Co-colonization was defined as a VRE-positive perirectal surveillance culture with an MRSA-positive anterior nares surveillance culture collected concurrently. Among 2,440 patients, 65 (2.7%) were co-colonized. Independent risk factors included age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01–1.05), admission to the medical ICU (OR 4.38, 95% CI 2.46–7.81), male sex (OR 1.93, 95% CI 1.14–3.30), and receiving antimicrobial drugs on a previous admission within 1 year (OR 3.06, 95% CI 1.85–5.07). None of the co-colonized patients would have been identified with clinical cultures alone. We report a high prevalence of VRE/MRSA co-colonization upon admission to ICUs at a tertiary-care hospital.

  • Mallards and Highly Pathogenic Avian Influenza Ancestral Viruses, Northern Europe PDF Version [PDF - 264 KB - 7 pages]
    V. J. Munster et al.
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    Surveillance studies in wild birds help generate prototypic vaccine candidates and diagnostic tests.

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    Outbreaks of highly pathogenic avian influenza (HPAI), which originate in poultry upon transmission of low pathogenic viruses from wild birds, have occurred relatively frequently in the last decade. During our ongoing surveillance studies in wild birds, we isolated several influenza A viruses of hemagglutinin subtype H5 and H7 that contain various neuraminidase subtypes. For each of the recorded H5 and H7 HPAI outbreaks in Europe since 1997, our collection contained closely related virus isolates recovered from wild birds, as determined by sequencing and phylogenetic analyses of the hemagglutinin gene and antigenic characterization of the hemagglutinin glycoprotein. The minor genetic and antigenic diversity between the viruses recovered from wild birds and those causing HPAI outbreaks indicates that influenza A virus surveillance studies in wild birds can help generate prototypic vaccine candidates and design and evaluate diagnostic tests, before outbreaks occur in animals and humans.

  • Isolate Removal Methods and Methicillin-resistant Staphylococcus aureus Surveillance PDF Version [PDF - 205 KB - 6 pages]
    F. Li et al.
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    The first Staphylococcus aureus isolate from a patient should be used to calculate oxacillin susceptibility frequency.

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    The effect of duplicate isolate removal strategies on Staphylococcal aureus susceptibility to oxacillin was compared by using antimicrobial test results for 14,595 isolates from statewide surveillance in Hawaii in 2002. No removal was compared to most resistant and most susceptible methods at 365 days and to the National Committee for Clinical Laboratory Standards (NCCLS) and Cerner algorithms at 3-, 10-, 30-, 90-, and 365-day analysis periods. Overall, no removal produced the lowest estimates of susceptibility. Estimates with either NCCLS or Cerner differed by <2% when the analysis period was the same; with either method, the difference observed between a 90- and a 365-day period was <1%. The effect of duplicate isolate removal was greater for inpatient than outpatient settings. Considering the ease of implementation and comparability of results, we recommend using the first isolate of a given species per patient to calculate susceptibility frequencies for S. aureus to oxacillin.

  • Vancomycin and Home Health Care PDF Version [PDF - 152 KB - 7 pages]
    T. G. Fraser et al.
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    Microbiologic diagnosis before hospital discharge and physician education may limit inappropriate vancomycin use in homecare patients.

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    The Hospital Infection Control Practices Advisory Committee published guidelines for prudent use of vancomycin to combat increasing resistance to antimicrobial drugs. Studies examining compliance with these guidelines primarily involve hospitalized patients. The growing practice of home use of antimicrobial drugs led to this retrospective cohort study that evaluated parenteral vancomycin use in patients receiving it through a homecare agency. We found that 39.2% of outpatients received vancomycin outside the guidelines, mainly because of prolonged empiric therapy, dosing convenience, and prolonged use after surgery. Patients were more likely to receive vancomycin appropriately if they were >65 years of age, had a history of malignancy, or were discharged from a medical service. In addition, obtaining wound cultures and attempting a microbiologic diagnosis led to more appropriate vancomycin use. Recommendations for prudent vancomycin use are often overlooked when selecting antimicrobial drugs for home infusion. The public health impact of this practice remains unknown.

  • Antibacterial Cleaning Products and Drug Resistance PDF Version [PDF - 151 KB - 6 pages]
    A. E. Aiello et al.
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    Levels of antimicrobial drug resistance did not differ significantly between persons in households that used antibacterial cleaning and hygiene products and those that did not.

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    We examined whether household use of antibacterial cleaning and hygiene products is an emerging risk factor for carriage of antimicrobial drug–resistant bacteria on hands of household members. Households (N = 224) were randomized to use of antibacterial or nonantibacterial cleaning and hygiene products for 1 year. Logistic regression was used to assess the influence of antibacterial product use in homes. Antibacterial product use did not lead to a significant increase in antimicrobial drug resistance after 1 year (odds ratio 1.33, 95% confidence interval 0.74–2.41), nor did it have an effect on bacterial susceptibility to triclosan. However, more extensive and longer term use of triclosan might provide a suitable environment for emergence of resistant species. Further research on this issue is needed.

  • Plasmodium falciparum Spatial Analysis, Western Kenya Highlands PDF Version [PDF - 218 KB - 7 pages]
    O. G. Munyekenye et al.
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    Parasite transmission is intense in the highlands, and these areas are vulnerable to epidemics.

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    We carried out a population-based study to determine the unbiased, age-specific Plasmodium falciparum prevalence, asexual and sexual parasite density, and spatial distribution to establish rates of infection at a site in western Kenya. Three cross-sectional surveys were carried out in western Kenya highlands. Blood samples were taken from 1,388 persons from 6 months to 75 years of age. Parasite prevalence and densities in the population decreased with age and distance from valley bottoms. Children from 1 to 4 years of age had the highest parasite prevalence (38.8%–62.8%); in adults, prevalence declined to 2.9%–24.1%. Malaria prevalence declined by an average of 19% from July to December 2002 across age groups. These observations suggest that parasite transmission is intense at this altitude. Asexual parasite density indicated clustering near major vector breeding habitats. Variability in seasonal prevalence indicates transmission instability and susceptibility to epidemics.

  • Botulinum Neurotoxin Detection and Differentiation by Mass Spectrometry PDF Version [PDF - 264 KB - 6 pages]
    J. R. Barr et al.
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    A new rapid, mass spectrometry-based method to detect and differentiate botulinal neurotoxins is described.

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    Botulinum neurotoxins (BoNTs) are proteases that cleave specific cellular proteins essential for neurotransmitter release. Seven BoNT serotypes (A–G) exist; 4 usually cause human botulism (A, B, E, and F). We developed a rapid, mass spectrometry–based method (Endopep-MS) to detect and differentiate active BoNTs A, B, E, and F. This method uses the highly specific protease activity of the toxins with target peptides specific for each toxin serotype. The product peptides derived from the endopeptidase activities of BoNTs are detected by matrix-assisted laser-desorption ionization time-of-flight mass spectrometry. In buffer, this method can detect toxin equivalents of as little as 0.01 mouse lethal dose (MLD)50 and concentrations as low as 0.62 MLD50/mL. A high-performance liquid chromatography–tandem mass spectrometry method for quantifying active toxin, where the amount of toxin can be correlated to the amount of product peptides, is also described.

  • Methicillin-resistant Staphylococcus aureus, Western Australia PDF Version [PDF - 226 KB - 7 pages]
    L. Dailey et al.
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    Endemic MRSA persists in Western Australia despite control measures.

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    Methicillin-resistant Staphylococcus aureus (MRSA) continues to be a notable cause of hospital-acquired infections. A statewide screening and control policy was implemented in Western Australia (WA) after an outbreak of epidemic MRSA in a Perth hospital in 1982. We report on statutory notifications from1998 to 2002 and review the 20-year period from 1983 to 2002. The rate of reporting of community-associated Western Australia MRSA (WAMRSA) escalated from 1998 to 2002 but may have peaked in 2001. Several outbreaks were halted, but they resulted in an increase in reports as a result of screening. A notable increase in ciprofloxacin resistance during the study period was observed as a result of more United Kingdom epidemic MRSA (EMRSA) -15 and -16. WA has seen a persistently low incidence of multidrug-resistant MRSA because of the screening and decolonization program. Non–multidrug-resistant, community-associated WAMRSA strains have not established in WA hospitals.

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