An outbreak of carbapenem-resistant Pseudomonas aeruginosa in a urology ward

Objective  To investigate an outbreak of carbapenem-resistant Pseudomonas aeruginosa (CRPA) in a urology ward.
Methods  Patients infected or colonized with CRPA were prospectively identified by daily laboratory surveillance. Routine infection-control measures were reinforced, disinfection protocols were revised, and a surveillance program was set up, analyzing cross-transmission in the nursing ward and environment cultures from urology wards and the operating theater. CRPA isolates from clinical and environment samples were studied by pulsed-field gel electrophoresis (PFGE), following Xba I and Spe I restriction.
Results  From February 1998 to September 2000, 59 adult urology patients were colonized or infected by CRPA. All patients had been operated on prior to identification of the CRPA isolate and 79% of these procedures were performed in the same cystoscopy room. No patients had received prior carbapenem therapy. No cross-transmission was detected, and environment cultures from the urology ward and theater were negative except for five samples collected in the cystoscopy room. PFGE identified a single clone in the isolates from different patients and the environment samples.
Conclusions  The PFGE analysis indicated that the CRPA outbreak resulted from the contamination of the cystoscopy room via an unsealed drain. The outbreak ended when the drain was sealed.     

我院重症监护室铜绿假单胞菌感染趋势及其耐药性分析

目的铜绿假单胞菌（Pseudomonas aeruginosa,PA）为院内感染的重要代表菌及临床分离率较高的菌株,在我院PA占所有菌株检出率的24.5%、占革兰阴性杆菌检出率的35.4%。通过对我院2006年1月-2009年6月期间4个重症监护室铜绿假单胞菌的感染情况及其耐药性进行分析,并与同期非重症监护室的病区进行比较,分析PA产碳青霉烯酶水解碳青霉烯类抗生素后同时携带多种耐药基因对其他药物敏感性的影响。方法采用Micro Scan全自动细菌鉴定和药敏分析仪,数据的分析采用WHONET软件。结果 4年间我院重症监护室铜绿假单胞菌检出数为559株,依次为：内科ICU272株、外科ICU149株、急诊ICU126株、儿科ICU12株。药敏结果显示：铜绿假单胞菌对大部分抗生素的敏感性呈逐年下降的趋势,尤其是重症监护室感染菌株。PA对碳青霉烯类抗菌素耐药的菌株产生多重甚至广泛耐药的几率较高。结论 4年间我院重症监护室铜绿假单胞菌对抗生素的耐药状况严重,尤其对头孢菌素,氨基糖苷类抗生素耐药率明显增加。对亚胺培南的耐药株同时携带多种耐药机制,产生多重耐药甚至泛耐药。多重耐药株和泛耐药株的检出亦呈逐年上升的趋势。     

Limiting the attributable mortality of nosocomial infection and multidrug resistance in intensive care units.

Severe nosocomial infections and multidrug resistance (MDR) are associated with a poor prognosis for patients in intensive care units. This is partly because most of these patients suffer from high disease severity and acute illness before the onset of infection. Nevertheless, the mortality attributed directly to infection can also be devastating. However, the attributable mortality can be limited by taking account of a number of key points. General infection prevention measures, prevention of cross-transmission and a policy of restricted antimicrobial use are all important because of their positive influence on the rates of infection and MDR. In turn, this will increase the odds for successful empirical coverage of the causative microorganism. Once infection occurs, benefits are to be expected from early recognition of the septic episode and prompt initiation of empirical antimicrobial therapy. The choice of empirical therapy should be based on the local bacterial ecology and patterns of resistance, the presence of risk-factors for MDR, and the colonisation status of the patient. Attention should also be given to adequate doses of antimicrobial agents and, if possible, elimination of the sources of infection, e.g., contaminated devices or intra-abdominal collections or leakages. In the latter case, timely surgical intervention is essential. In addition, haemodynamic stabilisation and optimisation of tissue oxygenation can save lives.     

Multiresistant Pseudomonas aeruginosa serogroup Ο:11 outbreak in an intensive care unit

Objective: To determine whether 15 multiresistant Pseudomonas aeruginosa isolates from an intensive care unit (ICU) outbreak were related, were endemic, and belonged to the Ο:12 European clone.
Methods: Forty-six P. aeruginosa isolates from a large hospital were investigated with respect to their antibiotic resistance profiles, serogroups, bacteriocin types and DNA fingerprints obtained by pulsed-field gel electrophoresis (PFGE) of genomic DNA digested with Xba l.
Results: Fourteen of the ICU outbreak isolates were indeed identical with respect to their serogroup, Ο:11, pyocin type, 10/a, and PFGE type, A. Clone A was endemic and dominant throughout the hospital, even though, within the ICU, it underwent phenotypic alterations, such as loss of cell wall lipopolysaccharide side-chains, or acquisition of ceftazidime and imipenem resistance. Bacteriocin typing was more discriminatory than serotyping, but PFGE could differentiate further among phenotypically identical strains. It also allowed the tracking of an Ο:6 strain, as it was becoming gradually more resistant and undergoing a bacteriocin-type conversion while remaining genotypically unaltered.
Conclusions: Using three typing methods, a nosocomial multiresistant strain distinct from the previously described dominant European Ο:12 clone was characterized, and the ability of PFGE to identify clonal isolates even when these appear phenotypically distinct was demonstrated.     

铜绿假单胞菌感染豚鼠后生物被膜形成的研究

目的 建立体内铜绿假单胞菌生物被膜模型，研究体内细菌生物被膜的组织学及细菌学特征。方法 通过吸入法使铜绿假单胞菌以气雾剂的形式吸入豚鼠肺内并生长定植，分别观察不同时期肺组织内细菌生物被膜的特征。结果 定植在肺内的铜绿假单胞菌以肉芽肿结节的形式存在，外周包绕类上皮细胞和成纤维细胞。结节内细菌被被膜基质所包绕并彼此连结，中间镶嵌宿主炎性细胞。接种后3周，肺内仍可见结节并培养出铜绿假单胞菌。结论 用吸入法可建立较稳定的铜绿假单胞菌肺感染生物被膜，其以肉芽肿结节的形式存在，宿主的反应细胞参与了生物被膜的形成。     

Candida glabrata fungaemia in intensive care units.

Candidaemia is increasingly important in intensive care units (ICUs). Compared with Candida albicans fungaemia, the impact of C. glabrata fungaemia on ICU patients is not well-known. The aim of this study was to investigate the clinical features, the antifungal susceptibility and the treatment outcomes of C. glabrata fungaemia in ICU patients. The medical records of ICU patients with candidaemia between 2000 and 2005 were reviewed retrospectively, and antifungal susceptibility testing was performed for isolates of C. glabrata. Among 147 episodes of candidaemia occurring in adult ICUs, C. glabrata was the second most common species and accounted for 45 (30%) episodes of candidaemia. The incidence of C. glabrata fungaemia was 1.3/1000 ICU admissions. Fluconazole resistance was found in 11% of C. glabrata isolates. The 30-day all-cause mortality rate was 58%. Therapeutic regimens containing amphotericin B were associated with better outcome. Despite higher fluconazole resistance, C. glabrata candidaemia was not associated with greater mortality than non-glabrata candidaemia in the ICU setting.     

Molecular epidemiology of Pseudomonas aeruginosa in intensive care units over a 10-year period (1998-2007)

Pseudomonas aeruginosa is one of the leading nosocomial pathogens in intensive care units (ICUs). The source of this microorganism can be either endogenous or exogenous. The proportion of cases as a result of transmission is still debated, and its elucidation is important for implementing appropriate control measures. To understand the relative importance of exogenous vs. endogenous sources of P. aeruginosa, molecular typing was performed on all available P. aeruginosa isolated from ICU clinical and environmental specimens in 1998, 2000, 2003, 2004 and 2007. Patient samples were classified according to their P. aeruginosa genotypes into three categories: (A) identical to isolate from faucet; (B) identical to at least one other patient sample and not found in faucet; and (C) unique genotype. Cases in categories A and B were considered as possibly exogenous, and cases in category C as possibly endogenous. A mean of 34 cases per 1000 admissions per year were found to be colonized or infected by P. aeruginosa. Higher levels of faucet contamination were correlated with a higher number of cases in category A. The number of cases in category B varied from 1.9 to 20 cases per 1000 admissions. This number exceeded 10/1000 admissions on three occasions and was correlated with an outbreak on one occasion. The number of cases considered as endogenous (category C) was stable and independent of the number of cases in categories A and B. The present study shows that repeated molecular typing can help identify variations in the epidemiology of P. aeruginosa in ICU patients and guide infection control measures.     

烧伤重症监护病房铜绿假单胞菌感染患者体外耐药性试验研究

目的了解铜绿假单胞菌在烧伤重症监护病房（ICU）耐药性分布,指导临床合理用药,降低医院感染率。方法回顾分析2009年1月至12月武汉市第三医院烧伤ICU特重度烧伤患者（烧伤面积≥50％TBSA）中分离的158株铜绿假单胞菌,按WHO推荐的NCCLS药敏试验标准中的Kirby—Bauer纸片扩散法进行药敏试验,分析菌株的临床分布特征及体外药敏结果。结果铜绿假单胞菌在烧伤ICU大面积烧伤患者中主要分布在烧伤创面,其次是痰液、深静脉导管及尿管。在13种临床常用抗生素中,表现为多重耐药,少数为泛耐药。其中美罗培南总耐药率为73．9％、亚胺培南86．5％、头孢哌酮／舒巴坦80．2％、头孢他啶82．0％,环丙沙星84．7％,阿米卡星82．0％。结论近年来多重耐药的铜绿假单胞菌在武汉市第三医院烧伤ICU大面积烧伤患者中广泛存在,对常用的广谱抗生素敏感性差。应当根据临床体外药敏结果及本科耐药细菌的流行动态分布合理选用抗生素,以取得良好的临床治疗效果,减少耐药菌产生;同时规范院内感染控制措施,减少耐药菌株的播散。     

Multiresistant Acinetobacter baumannii isolates in intensive care units in Greece

One hundred and twenty-one clinical isolates of Acinetobacter baumannii recovered from the intensive care units (ICUs) of nine tertiary-care hospitals in Athens, Greece were studied in order to determine whether the increasing appearance of resistant acinetobacters is due to the spread of epidemic strains. The majority of the isolates exhibited resistance to ampicillin–sulbactam, and the most common antibiotic resistance profiles comprised resistance to nine and eight of the 11 potentially active antibiotics tested, respectively. Pulsed-field gel electrophoresis showed that 68% of the isolates, recovered from all ICUs, belonged to two clonal groups, indicating inter-hospital dissemination of multiresistant A. baumannii in our region.     

铜绿假单胞菌lasR rhlR基因缺陷对大鼠慢性肺部感染的影响

目的观察铜绿假单胞菌（Pseudomonas aeruginosa，Pa）PAO1野生型及群体感应（quorum sensing，QS）系统的lasR rhlR基因缺陷型Pα菌株人工生物被膜致病性的差异，及QS系统的lasR rhlR基因在Pα生物被膜感染致病过程中的地位。方法从大鼠支气管内直接予以Pα（菌种为PAO1野生型和PAO1 lasR rhlR基因缺陷型）海藻酸盐微菌粒悬液（10^9CFU／ml）攻击，建立PAO1野生型及QS系统的lasR rhlR基因缺陷型菌株人工生物被膜肺部感染动物模型。分别于感染1周和2周后评估各组大鼠的肺部病理学、细菌学及细胞因子（IL-4、IL-10）反应的变化。结果感染1周和2周后，PAO1野生型组的肺部病理学改变和细菌学改变均明显重于PAO1 lasR rhlR基因缺陷组（P〈0．001）；感染1周后PAO1野生型组肺部的IL-4、IL-10水平都高于PAO1 lasR rhlR基因缺陷组（P〈0．01，P〈0．05）；2周后PAO1野生型组肺部IL-10水平进一步升高（P〈0．01），明显高于PAO1 lasR rhlR基因缺陷组（P〈0．001）。结论PAO1野生型组在病程中引起持久和严重的肺部感染，激发了TH2样免疫反应，而PAO1 lasR rhlR基因缺陷组的肺部病变明显轻于PAO1组，说明QS系统的lasR rhlR基因在Pα肺部感染的建立及慢性化发展过程中发挥着重要作用。     

Genome sequencing and characterization of an extensively drug-resistant sequence type 111 serotype O12 hospital outbreak strain of Pseudomonas aeruginosa

A series of extensively drug-resistant isolates of Pseudomonas aeruginosa from two outbreaks in UK hospitals were characterized by whole genome sequencing (WGS). Although these isolates were resistant to antibiotics other than colistin, we confirmed that they are still sensitive to disinfectants. The sequencing confirmed that isolates in the larger outbreak were serotype O12, and also revealed that they belonged to sequence type ST111, which is a major epidemic strain of P. aeruginosa throughout Europe. As this is the first reported sequence of an ST111 strain, the genome was examined in depth, focusing particularly on antibiotic resistance and potential virulence genes, and on the reported regions of genome plasticity. High degrees of sequence similarity were discovered between outbreak isolates collected from recently infected patients, isolates from sinks, an isolate from the sewer, and a historical isolate, suggesting that the ST111 strain has been endemic in the hospital for many years. The ability to translate easily from outbreak investigation to detailed genome biology by use of the same data demonstrates the flexibility of WGS application in a clinical setting.     

PER-1- and OXA-10-like β-lactamases in ceftazidime-resistant Pseudomonas aeruginosa isolates from intensive care unit patients in Istanbul, Turkey

The presence of PER-1- and OXA-10-like beta-lactamases was investigated by PCR in 49 ceftazidime-resistant Pseudomonas aeruginosa isolates from patients hospitalised in the 24-bed general intensive care unit of the Istanbul Faculty of Medicine during a 12-month period between February 1999 and February 2000. The clonal relatedness of the isolates was investigated by random amplified polymorphic DNA (RAPD) analysis, and the sequences of the PER-1 and OXA genes from all isolates were determined. The rates of resistance of the isolates to imipenem, aztreonam and cefepime were 98%, 92% and 96%, respectively, and to piperacillin and piperacillin-tazobactam were 41% and 37%, respectively. Using the double-disk synergy test, 37% (18/49) of the isolates were identified as extended-spectrum beta-lactamase producers. The PER-1 gene was identified in 86% (42/49) and the OXA-10 gene in 55% (27/49) of the ceftazidime-resistant isolates. Of isolates carrying the PER-1 gene, 48% (20/42) also carried the OXA-10 gene. The respective nucleotide sequences were identical for each isolate. Sixteen RAPD patterns were detected among the PER-1-positive isolates, but 60% (25/42) of the PER-1-positive isolates belonged to two distinct patterns, while the remainder exhibited a wide clonal diversity. The results indicated that the prevalence of PER-1- and OXA-10-like beta-lactamases remains high among ceftazidime-resistant P. aeruginosa isolates in Turkey.     

Metallo-beta-lactamase-producing clinical isolates of Acinetobacter species and Pseudomonas aeruginosa from intensive care unit patients of a tertiary care hospital

Prompt detection of metallo-beta-lactamase (MBL) producing isolates is necessary to prevent their dissemination. Frequency of MBLs producing strains among multidrug resistant (MDR) Acinetobacter species and Pseudomonas aeruginosa was evaluated in critical care patients using imipenem-EDTA disk method. One hundred MDR Acinetobacter spp. and 42 Pseudomonas aeruginosa were checked for MBL production, from January to June 2001. MBL was produced by 96.6 % of imipenem-resistant Acinetobacter isolates, whereas 100% imipenem-resistant Pseudomonas aeroginosa isolates were MBL producers. Carbapenem resistance in MDR Acinetobacter spp. and Pseudomonas aeruginosa isolates in this study was due to MBLs. This calls for strict infection control measures to prevent further dissemination.     

Typing of Pseudomonas aeruginosa strains in Norwegian cystic fibrosis patients

Objectives   Typing of Pseudomonas aeruginosa isolates from Norwegian cystic fibrosis (CF) patients with chronic Pseudomonas lung infection in order to see whether cross-infection might have occurred.
Methods   Isolates from 60 patients were collected during the years 1994–98, and typed by pulsed field gel electrophoresis.
Results   Seventy-one strains were identified. One large cluster of identical strains included 27 patients, and 13 smaller clusters of 2–4 patients were found (26 patients). Seven patients had a strain not shared by other patients (private strains). Harboring the main cluster strain was significantly associated with participation in summer camps and training courses ( P  = 0.004, chi-squared test). There were no associations with regular admissions to hospital (intravenous antibiotic courses) or smaller social gatherings of short duration. Small clusters and private strains were not associated with any of the risk factors. All strains were sensitive to colistin. The minimal inhibitory concentrations were generally lower in Norwegian P. aeruginosa strains compared with isolates from Danish patients.
Conclusions   Our results indicate that cross-infection with P. aeruginosa between cystic fibrosis patients has occurred.