Atypical toxin variant of Clostridium botulinum type B associated with infant botulism.

An atypical toxin variant of Clostridium botulinum (strain 657) was isolated from the feces of a 6-week-old female infant whose symptoms and clinical history were consistent with infant botulism. Toxin detected in the feces and the toxin produced by isolates from the feces and from two rectal swabs could be neutralized by type B botulinal antitoxin only at very high ratios of of antitoxin to toxin in the neutralization mixture. One international unit of type B antitoxin neutralized only about 10 lethal doses of 657 toxin as compared with approximately 10,000 lethal doses of conventional type B toxin from the Beans strain. Antitoxin prepared against 657 toxin was 10 times more effective against the conventional toxin than against the homologous toxin. Toxoid-antitoxin-binding studies indicate that both 657 toxin and type B toxin are heterogeneous and that both toxins may contain the same molecular variants, but that the proportions of the variants are different in each.     

Quantitation of Clostridium botulinum organisms and toxin in the feces of an infant with botulism.

A 4-month-old boy presented with symptoms and signs characteristic of infant botulism. Examination of feces revealed Clostridium botulinum type B and type B toxin. The numbers of C. botulinum and the amount of toxin in feces were measured throughout the 4-week period in hospital. The maximum numbers and amounts were detected in a fecal specimen collected 16 days after admission: this contained 8.4 X 10(6) C. botulinum type B colony-forming units and 61,440 mouse 100% lethal doses of type B toxin per g (wet weight) of feces. This latter figure is the highest fecal toxin titer reported yet for a case of infant botulism. By day 16, however, substantial improvement in the patient's clinical condition had occurred. This suggests that initiation of recovery from infant botulism is not necessarily preceded by a reduction in the numbers of C. botulinum organisms and the quantity of toxin in the gut.     

Quantities of Clostridium botulinum organisms and toxin in feces and presence of Clostridium botulinum toxin in the serum of an infant with botulism.

A 7-week-old boy presented with symptoms and signs characteristic of infant botulism, and the diagnosis was confirmed by the detection of Clostridium botulinum type A organisms and toxin in the feces. The levels of organisms and toxin in the feces were measured throughout the 81-day period in hospital. The maximum levels detected were 2.46 x 10(8) C. botulinum type A colony-forming units and 64,000 mouse 100% lethal doses of type A toxin per g (wet weight) of feces. C. botulinum toxin was also detected in two samples of the patient's serum, collected 3 and 10 days after admission. Improvement in the patient's clinical condition occurred before the levels of organisms and toxin in the feces reached their maxima. A slight improvement may also have occurred while toxin was still present in the serum.     

Dual toxin-producing strain of Clostridium botulinum type Bf isolated from a California patient with infant botulism

A retrospective study of Clostridium botulinum strains isolated from patients from California with infant botulism identified the fourth known C. botulinum strain that produces both type B and type F botulinum toxins. This unique strain represented 0.12% of the California infant botulism case isolates from 1976 to 2003. The relative concentrations of type B and F toxins produced were temperature dependent.     

Emergence of Clostridium botulinum type B-like nontoxigenic organisms in a patient with type B infant botulism.

We encountered a patient with infant botulism caused by a single clone of Clostridium botulinum type B. In the early convalescent phase, a C. botulinum type B-like nontoxigenic organism emerged in the feces instead. Growth inhibition of toxigenic strains by nontoxigenic strains was examined.     

Characterization of Clostridium botulinum strains associated with an infant botulism case in the United Kingdom

The sixth case of infant botulism in the United Kingdom was reported in 2001. The case was caused by a type B strain of Clostridium botulinum. Strains of C. botulinum were isolated from the baby's feces and from foodstuffs in the household in an attempt to document transmission. The aims of this study were to characterize the strains of C. botulinum associated with the botulism case. This was performed using a variety of techniques, including C. botulinum culture phenotypic properties, neurotoxin characterization, and pulsed-field gel electrophoresis (PFGE) banding patterns. Cultures associated with this case as well as isolates from stored and historical samples were analyzed and compared. C. botulinum type B PFGE patterns from the infant and from an opened container of infant formula were indistinguishable, while the PFGE profile of a strain presumably isolated from an unopened archival container was unique. The results suggest that the unopened brand of formula was not the source for transmission of spores to the infant and that the strain was distinct from previous botulism cases in the United Kingdom. Since environmental testing was not performed, it is not possible to deduce other sources of transmission.     

Kinetics of growth and toxigenicity of Clostridium botulinum in experimental wound botulism.

An animal model of wound botulism was developed in mice using an inoculum of Clostridium botulinum type A spores. The number of C. botulinum in infected wounds was quantitated by culturing on egg yolk agar, and the level of C. botulinum toxin in infected wound tissue was measured by a bioassay in mice and by an enzyme-linked immunosorbent assay. All infected mice receiving no further treatment developed neuroparalytic symptoms consistent with botulism after an incubation period of ca. 48 h, and all of these animals died. Serotherapy with C. botulinum type A antitoxin initiated 24 h postchallenge reduced the mortality rate to 5%. Treatment with metronidazole 2 to 24 h postchallenge resulted in recovery rates of 40 to 91%.     

Equine botulinum antitoxin for the treatment of infant botulism

Infant botulism is the most common form of human botulism in Argentina and the United States. BabyBIG (botulism immune globulin intravenous [human]) is the antitoxin of choice for specific treatment of infant botulism in the United States. However, its high cost limits its use in many countries. We report here the effectiveness and safety of equine botulinum antitoxin (EqBA) as an alternative treatment. We conducted an analytical, observational, retrospective, and longitudinal study on cases of infant botulism registered in Mendoza, Argentina, from 1993 to 2007. We analyzed 92 medical records of laboratory-confirmed cases and evaluated the safety and efficacy of treatment with EqBA. Forty-nine laboratory-confirmed cases of infant botulism demanding admission in intensive care units and mechanical ventilation included 31 treated with EqBA within the 5 days after the onset of signs and 18 untreated with EqBA. EqBA-treated patients had a reduction in the mean length of hospital stay of 23.9 days (P = 0.0007). For infants treated with EqBA, the intensive care unit stay was shortened by 11.2 days (P = 0.0036), mechanical ventilation was reduced by 11.1 days (P = 0.0155), and tube feeding was reduced by 24.4 days (P = 0.0001). The incidence of sepsis in EqBA-treated patients was 47.3% lower (P = 0.0017) than in the untreated ones. Neither sequelae nor adverse effects attributable to EqBA were noticed, except for one infant who developed a transient erythematous rash. These results suggest that prompt treatment of infant botulism with EqBA is safe and effective and that EqBA could be considered an alternative specific treatment for infant botulism when BabyBIG is not available.     

Characterization of the neurotoxin isolated from a Clostridium baratii strain implicated in infant botulism.

Botulism is widely known to result from ingestion of food containing botulinum neurotoxin produced in situ by certain strains of Clostridium botulinum. Infant botulism caused by C. botulinum, unlike the food-borne intoxication, is the toxicoinfectious form of botulism (S. S. Arnon, p. 331-345, in G. E. Lewis, ed., Biomedical Aspects of Botulism, 1981). The strain of Clostridium baratii implicated in infant botulism produced a neurotoxin that was neutralized with antiserum for botulinum neurotoxin serotype F (J. D. Hall, L. M. McCroskey, B. J. Pincomb, and C. L. Hatheway, J. Clin. Microbiol. 21:654-655, 1985). We developed a procedure to culture the toxigenic C. baratii (strain 6341) in dialysis bags and a simple purification scheme (precipitation of 900-ml culture supernatant with ammonium sulfate and two anion-exchange chromatographic steps at pH 5.5 and 8.0) that yielded up to 150 micrograms of purified neurotoxin. It is an approximately 140-kDa single-chain protein and has the following sequence of amino acid residues at the N terminus: Pro-Val-Asn-Ile-Asn-Asn-Phe-Asn-Tyr-Asn-Asp-Pro-Ile-Asn-Asn-Thr-Thr-Ile- Leu. Comparison of this amino acid sequence with those of the botulinum neurotoxin serotypes A, B, and E showed 40 to 50% identical residues in comparable positions. The specific toxicity of the neurotoxin, approximately 2 x 10(6) 50% lethal doses for mice per mg of protein injected, was not enhanced significantly by mild trypsinization, although the protease cleaved the neurotoxin within a disulfide loop that generated at least two primary fragments, approximately 47 and approximately 86 kDa, that remained linked by an interchain disulfide. These two fragments resembled the light and heavy chains of the well-characterized neurotoxin serotypes A, B, C, D, E, and F produced by C. botulinum.     

Repeat antimicrobial susceptibility testing of identical isolates.

Duplicate antimicrobial susceptibility test results were reviewed over a 1-year period to determine whether repeat testing of sequential isolates with the same identification from the same patient and specimen site was necessary. In our institution, repeat testing is always needed for coagulase-negative staphylococci and Pseudomonas aeruginosa and is needed after 3 days for members of the family Enterobacteriaceae, but it is not routinely necessary for Staphylococcus aureus.     

Genetic confirmation of identities of neurotoxigenic Clostridium baratii and Clostridium butyricum implicated as agents of infant botulism.

Two unusual neurotoxigenic clostridia isolated from fecal specimens from patients with type F and type E infant botulism were phenotypically identical to the existing species Clostridium baratii and C. butyricum, respectively. DNA hybridization experiments confirmed that one strain was C. baratii and that the other was C. butyricum. These species therefore do contain neurotoxigenic strains and are possible causes of infant botulism.     

Isolation of Clostridium botulinum from Honey.

Methods for the isolation of Clostridium botulinum from honey samples are described. A total of 9 of 90 honey samples were positive for C. botulinum; 6 of the positive samples had been fed to babies who developed infant botulism.     

Clinical isolates of Staphylococcus lugdunensis and S. schleiferi: bacteriological characteristics and susceptibility to antimicrobial agents

The bacteriological characteristics and susceptibility to antimicrobial agents of 108 clinical isolates of Staphylococcus lugdunensis and Staphylococcus schleiferi are described. Fifty out of 108 isolates were considered to be responsible for 16 documented infections, including some severe infections (endocarditis, bacteraemia, osteitis). A number of bacteriological characteristics enabled the identification of these species in the clinical microbiology laboratory: the absence of coagulase and protein A, and the presence of a fibrinogen affinity factor and thermonuclease along with other biochemical characteristics (ornithine and arginine decarboxylases, carbohydrate acidification, novobiocin susceptibility) differentiated these new species from other staphylococci; however, they did not possess virulence markers such as toxins or haemagglutinin, but were haemolytic. In this series, almost all isolates were susceptible to 22 antibiotics and 4 antiseptics representative of the main groups of antimicrobial agents. More information is needed on the ecology and epidemiology of these new opportunistic pathogens.     

Intraintestinal toxin in infant mice challenged intragastrically with Clostridium botulinum spores.

Conventionally raised suckling mice were injected intragastrically with 10(5) spores of a Clostridium botulinum type A culture. Botulism was not observed, but 80% or more of mice challenged when 8 to 11 days old had botulinum toxin in the large intestine 3 days later. Mice younger than 7 days or older than 15 days were resistant to the challenge. When in vivo toxin production was started by spores given to 9-day-old mice, toxin was present in the intestine at 1 through 7 days postchallenge but with greatest consistency between 1 and 4 days. Total toxin in an intestine ranged up to 1,920 50% lethal doses as titrated intraperitoneally in adult mice. The dose infecting 50% of a group of 9-day-old mice was 700 (95% confidence limits of 170 to 3,000) spores per animal. Toxin was formed in the lumen of the large intestine; it was not associated with the ileum. Injection of 10(5) spores intraperitoneally into 9-day-old mice resulted in toxin production in the large intestines of 30% of the test animals.     

Identification and antimicrobial resistance patterns of clinical isolates of Clostridium clostridioforme, Clostridium innocuum, and Clostridium ramosum compared with those of clinical isolates of Clostridium perfringens.

Clostridium ramosum, C. innocuum, and C. clostridioforme are frequently isolated from clinical specimens including blood. Because of Gram stain variability, a lack of spores, and atypical colonial morphology, identification of these species is often difficult. Three anaerobe identification kits were evaluated for their abilities to identify these species. For comparison, 11 strains of C. perfringens were evaluated in parallel. By using profile numbers and codebooks, the correct genus and species were identified, as follows: with the RapID ANA II kit, 100% (20 of 20) of C. ramosum isolates, 24% (5 of 21) of C. innocuum isolates, and 50% (10 of 20) of C. clostridioforme isolates; with the AnIDent kit, 60% (12 of 20) of C. ramosum isolates, 28% (6 of 21) of C. innocuum isolates, and 90% (18 of 20) of C. clostridioforme isolates; with the ATB32A kit, 70% (14 of 20) of C. ramosum isolates, 0% (0 of 21) of C. innocuum isolates, and 40% (8 of 20) of C. clostridioforme isolates. Profile numbers that overlapped several species were obtained as follows: with the RapID ANA II kit, 0% of C. ramosum isolates, 76% of C. innocuum isolates, and 40% of C. clostridioforme isolates; with the AnIDent kit 40% of C. ramosum isolates, 62% of C. innocuum isolates, and 5% of C. clostridioforme isolates; with the ATB32A kit, 15% of C. ramosum isolates, 52% of C. innocuum isolates, and 25% of C. clostridioforme isolates. One strain of C. innocuum was misidentified by the AnIDent kit, and the remainder yielded profile numbers that were not listed in the codebooks. The MICs of 11 antimicrobial agents including penicillin G, metronidazole, clindamycin, cefoxitin, cefotetan, imipenem, meropenem, amoxicillin-clavulanate, ampicillin-sulbactam, piperacillin-tazobactam, and vancomycin were determined by the agar dilution method. All C. perfringens strains were susceptible to all antimicrobial agents tested. Various levels of resistance to cefoxitin, cefotetan, and penicillin G were noted with C. ramosum, C. clostridioforme, and C. innocuum. In addition, resistance to clindamycin was noted with C. ramosum (5%) and C. innocuum (10%). Most strains of C. innocuum were only moderately susceptible to vancomycin (MIC at which 90% of strains are inhibited, 4 micrograms/ml).     

Isolation of an organism resembling Clostridium barati which produces type F botulinal toxin from an infant with botulism.

A method was established to freeze selected human O erythrocytes and to thaw them as necessary for use in the immune adherence hemagglutination test. This method ensured interrun reproducibility and eliminated the necessity to screen blood donors (fresh cells) for acceptable C3b receptor site sensitivity.     

Frequency and antimicrobial susceptibility of clinical isolates of enterococci

A study was performed to determine the frequency and antimicrobial susceptibility ofEnterococcus species in clinical specimens. Of 943 aesculinpositive isolates, 873 (92 %) were identified as enterococci (737Enterococcus faecalis, 129Enterococcus faecium and 7 otherEnterococcus species). High-level resistance to gentamicin was found in 15.2 % ofEnterococcus faecalis, but not inEnterococcus faecium; 58 % ofEnterococcus faecium were resistant to gentamicin at a concentration of 64 mg/l. None of the isolates were shown to possess vancomycin resistance.     

First case of infant botulism caused by Clostridium baratii type F in California

In late 2003 a severely hypotonic neonate, just 38 h old at onset of illness, was found to have infant botulism caused by neurotoxigenic Clostridium baratii type F. Environmental investigations failed to identify a source of this strain. This is the youngest patient reported to have infant botulism and the fifth instance of infant botulism caused by C. baratii type F.     

Isolation and enumeration of Clostridium botulinum by direct inoculation of infant fecal specimens on egg yolk agar and Clostridium botulinum isolation media

Direct plating of stool specimens on selective (Clostridium botulinum isolation) and nonselective (egg yolk agar) media was evaluated as an aid in confirming infant botulism. C. botulinum was isolated from 13 of 14 culture-positive specimens with C. botulinum isolation and from 8 of 14 egg yolk agar. No lipase reaction was seen on plates of 31 culture-negative specimens.