Biofilm-related infections of cerebrospinal fluid shunts

Cerebrospinal fluid (CSF) shunts carry a high risk of complications. Infections represent a major cause of shunt failure. Diagnosis and therapy of such infections are complicated by the formation of bacterial biofilms attached to shunt surfaces. This study correlated the pathophysiology and clinical course of biofilm infections with microscopical findings on the respective shunts. Surface irregularities, an important risk-factor for shunt colonisation with bacteria, were found to increase over time because of silicone degradation. Scanning electron-microscopy (SEM) documented residual biological material (dead biofilm), which can further promote extant bacterial adhesion, on newly manufactured shunts. Clinical course and SEM both documented bacterial dissemination against CSF flow and the monodirectional valve. In all cases, biofilms grew on both the inner and outer surfaces of the shunts. Microscopy and conventional culture detected all bacterial shunt infections. Analyses of 16S rDNA sequences using conserved primers identified bacteria in only one of three cases, probably because of previous formalin fixation of the samples.     

Random amplified polymorphic DNA and plasmid analyses used in investigation of an outbreak of multiresistant Klebsiella pneumoniae.

Multiresistant Klebsiella pneumoniae strains with plasmid-borne extended-spectrum beta-lactamases (ESBL) are increasingly frequent nosocomial pathogens. A major outbreak of clinical infections, mainly involving patients in the Newborn Services Unit with limited spread to adult patients, occurred at our hospital. This epidemic was investigated by typing the isolates phenotypically and with random amplified polymorphic DNA analysis (RAPD) and plasmid analysis. Forty-eight isolates, consisting of 44 consecutive clinical isolates and 4 selected surveillance isolates, were studied. A single decamer primer was used for the RAPD, and this was effective in demonstrating that the majority of isolates (45 of 48) had the same profile. Three other isolates had different RAPD patterns identifying them as nonepidemic strains. Plasmids were extracted by alkaline lysis with Magic-miniprep kits from 10 isolates selected to represent the epidemic and nonepidemic strains. This method produced small (< 20-kb) plasmids; larger ESBL-carrying plasmids were not produced, but the small plasmids nonetheless allowed strain differentiation. Antibiotic susceptibility patterns alone were not reliable as strain indicators, since some isolates with the RAPD pattern characteristic of the epidemic strains did not express ESBL and therefore were susceptible to extended-spectrum cephalosporins. The investigation showed the predominance of a single epidemic strain that was transmitted between patients in the Newborn Services Unit. RAPD was the best of the methods used for detecting strain differences, and its speed and ability to type a wide variety of species suggest that it will be an increasingly useful molecular epidemiologic tool.     

Bacteriological examination of removed cerebrospinal fluid shunts.

A conventional method of bacteriological examination of removed cerebrospinal fluid shunts was compared with another method which relies on microscopic and cultural examination of intraluminal fluid. Fifty-five shunts were tested. All eight cases of clinical shunt infection gave positive results with the latter method, whereas a further 23 shunts yielded positive cultures by the conventional method in the absence of clinical infection. The consequences of missed infections due to omission of microscopic examination and overdiagnosis using the conventional culture method are discussed.     

First isolation of metallo-beta-lactamase-producing multiresistant Klebsiella pneumoniae from a patient in Brazil

A multiresistant Klebsiella pneumoniae isolate was taken from the blood of a 75-year-old patient with nosocomial pneumonia who developed septic shock and failed therapy with imipenem. The isolate presented an MIC of imipenem of 128 microg/ml, and the production of a metallo-beta-lactamase was confirmed by phenotypic and genotypic techniques. We here report, for the first time, the detection of a metalloenzyme (IMP-1)-producing K. pneumoniae clinical strain in Latin America. The gene responsible for this phenotype was found to be bla(IMP-1), carried in a class 1 integron.     

Adherence properties of an mrkD-negative mutant of Klebsiella pneumoniae.

The role of the mrkD gene in attachment by a type 3 fimbriate Klebsiella pneumoniae strain was further characterized. A clinical isolate, K. pneumoniae IA565, was found to contain two copies of the gene encoding the fimbrial subunit, mrkA, and one copy of the gene encoding the adhesin subunit, mrkD. One copy of mrkA was located on the bacterial chromosome, and the other copy was associated with mrkD and located on a plasmid. The plasmid-borne mrk gene cluster was lost when K. pneumoniae IA565 was subcultured serially in broth at 44 degrees C. The resulting mrkD-negative strain, designated K. pneumoniae IApc35, did not exhibit the following adherence characteristics associated with K. pneumoniae possessing MrkD-positive fimbriae: agglutination of tannic acid-treated human erythrocytes and attachment to trypsinized human buccal cells. However, K. pneumoniae IApc35 produced type 3 fimbriae that were composed of the characteristic 21.5-kDa major fimbrial subunit, were reactive with specific serum, and were visualized specifically by immunoelectron microscopy. K. pneumoniae IApc35 retained a copy of the mrkA gene on its chromosome. This mrkA-containing gene cluster could be complemented by a recombinant plasmid carrying only the mrkD gene, resulting in restoration of the K. pneumoniae IA565-like adhesive phenotype and demonstration of type 3 filament-associated MrkD subunits by using colloidal gold labeling and immunoelectron microscopy. These data indicate that K. pneumoniae may contain multiple copies of the mrk genes which may be present simultaneously on both plasmid and chromosomal DNAs and which may encode fimbriae with different binding specificities.     

一株多重耐药肺炎克雷伯菌KF3的质粒研究

目的 通过对肺炎克雷伯菌KF3质粒DNA全序列测定,从基因组水平研究质粒DNA的结构、功能基因和与宿主菌耐药相关性.方法 碱裂解法提取质粒DNA,构建质粒DNA文库并测序.采用Phred/Phrap/Consed软件包进行序列拼接,Glimmer软件预测开放阅读框架(ORF)及功能分析.结果 构建包含3个质粒DNA的pUC18文库和Fosmid文库,测序获得3个质粒全序列.功能注释分析发现3个质粒均为可接合转移质粒,编码大量耐药相关基因.结论 肺炎克雷伯菌KF3的3个质粒都是可接合转移质粒,将耐药基因在细菌间进行水平转移,造成了耐药菌的播散.     

Outbreak of infection with a multiresistant Klebsiella pneumoniae strain associated with contaminated roll boards in operating rooms

An outbreak with a multiresistant Klebsiella pneumoniae (MRKP) strain among seven patients admitted to the adult intensive care unit (ICU) of a regional teaching hospital in The Netherlands was investigated. Epidemiologic investigations revealed a short delay between an operation and the acquisition of the MRKP strain. A case-control study comprising 7 cases and 14 controls was conducted to identify the risk factors associated with the acquisition of the MRKP strain. An operation at each of two operation rooms was strongly associated with the acquisition of the MRKP strain: odds ratio of 36 (95% confidence interval, 2.7 to 481.2; P=0.003, Fisher exact two-tailed test). Cultures of environmental specimens of the operation rooms revealed contamination of the roll boards used to transport patients from the bed to the operation table with the MRKP strains. Molecular genotyping of the isolates revealed clonal similarity between the isolates of the seven cases, isolates from environmental specimen cultures, and in addition, an MRKP isolate from a re-patriated ICU patient from earlier that year. The outbreak ended after cleaning and replacement of the roll boards in the operation rooms and implementation of additional barrier precautions for colonized or infected patients. It was concluded that two operation rooms played a significant role in the transmission of an MRKP strain between ICU patients during the presented outbreak.     

Detection of multiresistant ceftazidime-susceptible Klebsiella pneumoniae isolates lacking TEM-26 after class restriction of cephalosporins

A multitude of extended spectrum beta-lactamases (ESBLs) have evolved in response to the use of late generation cephalosporins. In those hospitals where Klebsiella pneumoniae and other bacteria possessing these enzymes flourish, many interventions have been applied to reduce this trend. We instituted a policy of class restriction of cephalosporins in our hospital in 1996 that led to a 44% reduction in ceftazidime-resistant K. pneumoniae hospital-wide and an 87% decrease in the surgical intensive care unit. Another interesting outcome of this strategy was the identification of multiresistant K. pneumoniae, which was now susceptible to ceftazidime. Characterization of these novel isolates demonstrated that the TEM-26 enzyme, which was responsible for ceftazidime resistance in our earlier described outbreak, was lacking in most of the isolates examined. Among the remaining ceftazidime-resistant K. pneumoniae, TEM-26 was also absent, and new enzymes that hydrolyze ceftazidime were detected. Loss of ceftazidime-hydrolyzing beta-lactamases was observed after in vitro passage of ceftazidime-resistant K. pneumoniae on antibiotic-free media. These findings suggest that class restriction of cephalosporins may increase susceptibility among extended-spectrum beta-lactamase-producing pathogens.     

Transferable plasmid mediating resistance to multiple antimicrobial agents in Klebsiella pneumoniae isolates in Greece

Objective   To investigate the underlying resistance mechanisms in 10 Klebsiella pneumoniae isolates.
Methods   Ten K. pneumoniae strains according to distinct bacteriocin typing and REP-PCR, were examined for their plasmid content, their ability to transfer their resistance to aminoglycosides and third-generation cephalosporins, and their production of aminoglycoside-modifying enzymes and β -lactamases.
Results   Transfer of resistance to the above-mentioned antibiotics as well as to co-trimoxazole and tetracycline in Escherichia coli strain RC 85 at a frequency of 5–10⁶ was achieved for all strains by conjugation. Similar strains harbor a self-transferable multiresistant plasmid (80 kb) with similar Eco RI and Hind III restriction patterns. This plasmid encodes an extended-spectrum β -lactamase which confers high-level resistance to third-generation cephalosporins and aztreonam. It produces SHV-5 β -lactamase, as demonstrated by isoelectric focusing and DNA sequencing. Aminoglycoside resistance was co-transferred, and AAC(6')-I, mediating resistance to gentamicin, tobramycin, netilmicin and amikacin, and AAC(3)-I, mediating resistance to gentamicin and sisomycin, were encoded in all isolates and their transconjugants, while APH(3')-I, mediating resistance to kanamycin and neomycin, was encoded in seven strains.
Conclusions   It appears that a multiresistant transferable plasmid encoding the SHV-5 β -lactamase, causing unusually high resistance to ceftazidime and aztreonam, and the combination AAC(6')-I + AAC(3)-I of acetylating enzymes causing, also resistance to all clinically available aminoglycosides, is established in K. pneumoniae in Greece.     

Ornithine decarboxylating strains of Klebsiella pneumoniae demonstrated by DNA-DNA hybridization

Genotypic relatedness was assessed to clarify the taxonomic position of strains phenotypically behaving like K. pneumoniae, but for the ornithine reaction. Using DNA-DNA hybridization it could be shown that 25 non-motile ornithine decarboxylating strains showed high genotypic relatedness to the type strain of K. pneumoniae. Thus, it is proposed that they be considered as ornithine decarboxylating strains of the species K. pneumoniae. The API 20E system was used for phenotypic characterization, but the API code obtained by these strains was not registered in the API Profile Index. However, except for the ornithine reaction the isolates behaved as typical K. pneumoniae. Three ornithine negative strains of E. aerogenes were identified as K. pneumoniae by the API 20E System, but they showed high genotypic relatedness to the type strain of E. aerogenes.     

Adherence of Erythrocytes to Mycoplasma pneumoniae

The human pathogen Mycoplasma pneumoniae adheres to a variety of cells, including erythrocytes. A hemadsorption technique was developed to quantitate adherence by photometric measurement of lysates of erythrocytes that attached to sheets of M. pneumoniae grown in cups of Linbro plates. Attachment of sheep erythrocytes (SE) increased with higher ionic strength, was unaffected by minor pH variations (6 to 9), and was blocked by anti-M. pneumoniae antiserum, but was not inhibited by a variety of sugars, amino acids, and bovine serum albumin. The reaction was time and temperature dependent. The temperature curve showed peaks at 14 and 28 degrees C with untreated SE but only one peak at about 38 degrees C with glutaraldehyde-treated SE. The temperature dependence indicated involvement of either metabolic or membrane activities in the binding process. Trypsin treatment of the M. pneumoniae sheet abolished adherence of SE but was only partially effective with human erythrocytes and noneffective with rabbit erythrocytes. The binding capacity of the mycoplasma cells for SE was restored by incubation in growth medium for 3 to 4 h; this restoration was inhibited by 10 mug of chloramphenicol per ml. Neuraminidase treatment of SE removed their attachment capacity but had no effect on attachment of rabbit erythrocytes and only a slight effect on attachment of human erythrocytes. Pretreatment of M. pneumoniae with neuraminic acid partially blocked the adherence of SE, whereas rabbit erythrocyte attachment was not affected. Attached SE could be detached by trypsin, but not by neuraminidase. For human and rabbit erythrocytes, the results suggest binding mechanisms other than the interaction between neuraminidase-sensitive receptors and protein-containing binding sites shown for SE.     

Short-term response of brain tissue to cerebrospinal fluid shunts in vivo and in vitro.

The purpose of the studies was to determine how gross physical characteristics of cerebrospinal fluid (CSF) shunts and the cellular proliferative response to shunts contribute to shunt obstruction. Ventricular catheters with round holes, slots, and flanges were implanted into the lateral ventricles of rabbits for 4 weeks. All shunt designs were subject to ingrowth of tissue from the ventricle wall or choroid plexus. There were no qualitative or quantitative differences between normal and hydrocephalic rabbits. Astroglial cells from newborn mice were cultured on shunt catheters for 2 or 4 weeks. The growth of these cells was poor, probably because the cells cannot attach well to the silicone rubber substrate. Contact between the shunt catheter and vascularized brain tissue is the most important factor in the genesis of shunt obstruction.     

Klebsiella pneumoniae strains producing extended-spectrum beta-lactamases in Spain: microbiological and clinical features

Extended-spectrum β-lactamases (ESBL) of the CTX-M, SHV, and TEM families were recognized in 76 (67%), 31 (27%), and 6 (5%) isolates, respectively, among 162 ESBL-producing Klebsiella pneumoniae (ESBL-Kp) strains obtained in a multicenter study in Spain. Predisposing factors for ESBL-Kp acquisition included invasive procedures, mechanical ventilation, and previous antimicrobial use.     

Indole-positive strains of Klebsiella pneumoniae producing hydrogen sulfide in iron-agar slants

The biochemical characteristics of six strains of Klebsiella pneumoniae that produced H2S in TSI slants are described. All were biotypical except for the consistent characteristic of indole production. It is suggested that the qualities of H2S and indole production are linked biochemical features acquired by episomal transfer. The attention of bacteriology laboratory workers is directed to these strains, which are easily distinguished biochemically from other H2S-producing organisms by their otherwise biotypical pattern.     

Heterogeneity of rRNA gene restriction patterns of multiresistant serotype 6B Streptococcus pneumoniae strains.

Three multiresistant serotype 6B Streptococcus pneumoniae strains were isolated from the middle ear fluids of children undergoing tympanostomy in Atlanta. Because multiresistant 6B pneumococci have been reported to spread from a single clone, the three isolates were compared with 13 other multiresistant 6B pneumococci by hybridization of endonuclease-restricted DNA fragments with a digoxigenin-labeled cDNA probe complementary to 16 and 23S rRNAs (ribotyping). The ear isolates were heterogeneous, whereas six of the other pneumococcal isolates were alike, indicating a need for additional studies to determine the possibility of clonal spread.     

Solexa测序法研究肺炎克雷伯菌质粒基因组的耐药基因

目的 通过Solexa高通量测序法研究肺炎克雷伯菌的质粒与耐药性的关系.方法 菌株为7年临床分离的206株肺炎克雷伯菌.提取所有菌的全部质粒DNA,Solexa高通量测序获得大规模的短序列.SOAP软件对质粒基因进行分析拼接,分析结果与相关数据库进行比对.MAQ软件分析质粒基因组包含的超广谱β-内酰胺酶(ESBL)多样性及单核苷酸多态性(SNP)情况.结果 肺炎克雷伯菌质粒基因组中已知的直接与耐药相关的基因就有13种.质粒基因组中存在多个ABC主动外排转运系统.发现4种编码β-内酰胺酶的ORF,其中SHV型ESBLs分布最广.系统分析了206株肺炎克雷伯菌质粒基因组中SHV型ESBLs的SNPs位点,发现存在着大量的非同义替换SNPs位点.结论 发现质粒中SHV型ESBLs基因可能受到选择压力,存在着大量的非同义替换SNPs位点.肺炎克雷伯菌质粒存在外排药物耐药方式,从而形成低水平的非特异多重耐药.     

Adherence to respiratory epithelia by recombinant Escherichia coli expressing Klebsiella pneumoniae type 3 fimbrial gene products.

We examined the role of Klebsiella fimbrial types 1 and 3 in mediating adherence to human buccal and tracheal cells and to lung tissue sections. We found that clinical isolates of Klebsiella pneumoniae producing type 3 fimbriae and Escherichia coli HB101 containing a recombinant plasmid encoding expression of Klebsiella type 3 fimbriae (pFK10) demonstrated increased adherence to tracheal cells, trypsinized buccal cells, and lung tissue sections, in contrast to nonfimbriate and to type 1 fimbriate bacteria. Adherence by type 3 fimbriate bacteria was inhibited by purified type 3 fimbriae and Fab fragments derived from type 3 fimbrial-specific polyclonal immunoglobulin G. Type 3 fimbriae mediated attachment to the basolateral surface of tracheal cells and to the basal epithelial cells and the basement membrane regions of bronchial epithelia. Using an E. coli transformant (pDC17/pFK52), which expresses nonadherent P fimbrial filaments, along with the type 3 fimbrial adhesin (MrkD), we demonstrated that type 3 fimbrial attachment to respiratory cells was attributable to the MrkD adhesin subunit. Subsequent experiments demonstrated that the epithelial target of the type 3 fimbrial adhesin was most likely a peptide molecule rather than a carbohydrate. The results of this study demonstrate that, in vitro, the Klebsiella type 3 fimbrial adhesin mediates adherence to human respiratory tissue.