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Genetic definition of the substrate selectivity of outer membrane porin protein OprD of Pseudomonas aeruginosa.

Earlier studies proved that Pseudomonas aeruginosa OprD is a specific porin for basic amino acids and imipenem. It was also considered to function as a nonspecific porin that allowed the size-dependent uptake of monosaccharides and facilitation of the uptake of quinolone and other antibiotics. In the present study, we utilized P. aeruginosa strains with genetically defined levels of OprD to characterize the in vivo substrate selectivity of this porin. An oprD::omega interposon mutant was constructed by gene replacement utilizing an in vitro mutagenized cloned oprD gene. In addition, OprD was overexpressed from the lac promoter by cloning the oprD gene into the broad-host-range plasmid pUCP19. To test the substrate selectivity, strains were grown in minimal medium with limiting concentrations of the carbon sources glucose, gluconate, or pyruvate. In minimal medium with 0.5 mM gluconate, the growth rates of the parent strain H103 and its oprD::omega mutant H729 were only 60 and 20%, respectively, of that of the OprD-overexpressing strain H103(pXH2). In contrast, no significant differences were observed in the growth rates of these three strains on glucose or pyruvate, indicating that OprD selectively facilitated the transport of gluconate. To determine the role of OprD in antibiotic uptake, nine strains representing different levels of OprD and OprF were used to determine the MICs of different antibiotics. The results clearly demonstrated that OprD could be utilized by imipenem and meropenem but that, even when substantially overexpressed, it could not be significantly utilized by other beta-lactams, quinolones, or aminoglycosides. In addition, competition experiments confirmed that imipenem had common binding sites with basic amino acids in the OprD channel, but not with gluconate or glucose.

Amino Acids, Diamino↗

Characterization of a large outbreak by CTX-M-1-producing Klebsiella pneumoniae and mechanisms leading to in vivo carbapenem resistance development.

All extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae isolates from patients admitted to and adult intensive care unit were prospectively documented from 2002 to 2005, when a large outbreak (51 patients affected) of multiresistant ESBL-producing Klebsiella pneumoniae infection was detected. The involvement of a single K. pneumoniae clone was demonstrated by pulsed-field gel electrophoresis. In addition to the ESBL-mediated resistance, the epidemic strain uniformly showed cross-resistance to ciprofloxacin, gentamicin, tobramycin, trimethoprim-sulfamethoxazole, and tetracycline, whereas resistance to the beta-lactam-beta-lactamase inhibitor combinations was variable. The ESBL involved was CTX-M-1, as demonstrated by isoelectric focusing, PCR amplification, and sequencing. CTX-M-1 as well as the aminoglycoside resistance determinants were encoded in a 50-kb plasmid that could be transferred to Escherichia coli only by transformation. In two of the infected patients, carbapenem resistance development (MICs of 8 to 12, 16, and >32 microg/ml for imipenem, meropenem, and ertapenem, respectively) was documented, both in clinical samples and in intestinal colonization studies. The analysis of the outer membrane proteins of the carbapenem-susceptible and -resistant isolates revealed that the former expressed only one of the two major porins, OmpK36, whereas the latter did not express either of them. In one of the cases, the lack of expression of OmpK36 was demonstrated to be mediated by the interruption of the coding sequence by the insertion sequence IS26. This is the first report of a large outbreak of CTX-M-1-producing Enterobacteriaceae and, curiously, the first documented description in the literature of CTX-M-1 in K. pneumoniae, despite the fact that this enzyme has been found in multiple species. Furthermore, we document and characterize for the first time carbapenem resistance development in CTX-M-1-producing Enterobacteriaceae.

Anti-Bacterial Agents↗

blaVIM-2 and blaVIM-7 carbapenemase-producing Pseudomonas aeruginosa isolates detected in a tertiary care medical center in the United States: report from the MYSTIC program.

Two Pseudomonas aeruginosa strains resistant to beta-lactams, fluoroquinolones, aminoglycosides, tetracyclines, and carbapenems and susceptible only to polymyxin B (MIC <or= 2 microg/ml) were identified as part of the Meropenem Yearly Susceptibility Test Information Collection program. Metallo-beta-lactamase screening tests were positive, PCR yielded products with blaVIM primers, and sequence analysis revealed blaVIM-7 and blaVIM-2. The isolates had distinct ribotype and pulsed-field gel electorphoresis patterns and appeared independently, remote in time and location, at the same cancer center.

Academic Medical Centers↗

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).

Bacteriological Techniques↗

Extremely high incidence of macrolide and trimethoprim-sulfamethoxazole resistance among clinical isolates of Streptococcus pneumoniae in Taiwan.

From January 1996 to December 1997, 200 isolates of Streptococcus pneumoniae recovered from 200 patients treated at National Taiwan University Hospital were serotyped and their susceptibilities to 16 antimicrobial agents were determined by the agar dilution method. Sixty-one percent of the isolates were nonsusceptible to penicillin, exhibiting either intermediate resistance (28%) or high-level resistance (33%). About two-fifths of the isolates displayed intermediate or high-level resistance to cefotaxime, ceftriaxone, cefepime, imipenem, and meropenem. Extremely high proportions of the isolates were resistant to erythromycin (82%), clarithromycin (90%), and trimethoprim-sulfamethoxazole (TMP-SMZ) (87%). Among the isolates nonsusceptible to penicillin, 23.8% were resistant to imipenem; more than 60% displayed resistance to cefotaxime, ceftriaxone, cefepime, and carbapenems; 96.7% were resistant to erythromycin; and 100% were resistant to TMP-SMZ. All isolates were susceptible to rifampin and vancomycin. The MICs at which 50% and 90% of the isolates were inhibited were 0.12 and 1 microgram/ml, respectively, for cefpirome, and 0.12 and 0.25 microgram/ml, respectively, for moxifloxacin. Six serogroups or serotypes (23F, 19F, 6B, 14, 3, and 9) accounted for 77.5% of all isolates. Overall, 92.5% of the isolates were included in the serogroups or serotypes represented in the 23-valent pneumococcal vaccine. The incidence of macrolide and TMP-SMZ resistance for S. pneumoniae isolates in Taiwan in this study is among the highest in the world published to date.

Adolescent↗

Recurrent "Flexispira rappini" bacteremia in an adult patient undergoing hemodialysis: case report.

A blood culture from a 65-year-old febrile man undergoing hemodialysis revealed, 5 days after inoculation, an unusual gram-negative fusiform rod with darting motility. During another episode of fever 21 days later, this Campylobacter-like organism was again recovered from three blood cultures and subcultured under an H2-enriched microaerobic atmosphere. The organism was catalase negative and oxidase positive and hydrolyzed urea rapidly. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis analysis of whole-cell proteins was indistinguishable from that of "Flexispira rappini" LMG 8738 described by Archer et al. in 1988 (J. R. Archer, S. Romero, A. E. Ritchier, M. E. Hamacher, B. M. Steiner, J. H. Bryner, and R. F. Schell, J. Clin. Microbiol. 26:101-105, 1988). The analysis of the 16S ribosomal DNA sequence revealed a similarity of 99.3% between the two strains. The patient recovered completely after a 4-week course of meropenem therapy. This is the first reported case of a recurrent "F. rappini" bacteremia in an adult patient, which confirms that this organism may be an invasive pathogen in immunocompromised patients, like other newly described Helicobacter species.

Aged↗

Comparison of agar diffusion methodologies for antimicrobial susceptibility testing of Pseudomonas aeruginosa isolates from cystic fibrosis patients.

Pseudomonas aeruginosa is the most common pathogen infecting the lungs of patients with cystic fibrosis (CF). Improved antimicrobial chemotherapy has significantly increased the life expectancy of these patients. However, accurate susceptibility testing of P. aeruginosa isolates from CF sputum may be difficult because the organisms are often mucoid and slow growing. This study of 597 CF isolates of P. aeruginosa examined the correlation of disk diffusion and Etest (AB BIODISK, Solna, Sweden) results with a reference broth microdilution method. The rates of interpretive errors for 12 commonly used antipseudomonal antimicrobials were determined. The disk diffusion method correlated well (zone diameter versus MIC) for all of the agents tested. However, for mucoid isolates, correlation coefficients (r values) for piperacillin, piperacillin-tazobactam, and meropenem were <0.80. The Etest correlation with reference broth microdilution results (MIC versus MIC) was acceptable for all of the agents tested, for both mucoid and nonmucoid isolates. Category interpretation errors were similar for the disk diffusion and Etest methods with 0.4 and 0.1%, respectively, very major errors (false susceptibility) and 1.1 and 2.2% major errors (false resistance). Overall, both agar diffusion methods appear to be broadly acceptable for routine clinical use in susceptibility testing of CF isolates of P. aeruginosa.

Agar↗

Outbreak of infection with multidrug-resistant Klebsiella pneumoniae carrying bla(IMP-8) in a university medical center in Taiwan.

Klebsiella pneumoniae strains with the transferable carbapenem-hydrolyzing metallo-beta-lactamases, which include IMP- and VIM-type enzymes, remain extremely rare. To investigate whether IMP- or VIM-producing K. pneumoniae isolates had spread at a university medical center in Taiwan, a total of 3,458 clinical isolates of K. pneumoniae consecutively collected in 1999 and 2000 were tested by the agar diffusion method, colony hybridization, PCR, and nucleotide sequencing. A total of 40 isolates (1.2%), or 17 nonrepetitive isolates, from 16 patients were found to carry bla(IMP-8), a metallo-beta-lactamase gene recently identified from a K. pneumoniae strain in Taiwan. Carriage of bla(VIM) or other bla(IMP) genes was detected in none of the remaining isolates. Of the 17 nonrepetitive bla(IMP-8)-positive isolates, 15 isolates (88.2%) appeared susceptible to imipenem (MICs, <or=4 microg/ml) and meropenem (MICs, <or=1 microg/ml), indicating the difficulty in detecting bla(IMP-8) in K. pneumoniae by routine susceptibility tests; 14 isolates (82.4%) produced SHV-12 as well; and 14 isolates (82.4%) were also resistant to fluoroquinolones. The organisms caused wound infections in eight patients and bloodstream infections in three patients. They were not directly associated with the death of nine patients. Before the recovery of the bla(IMP-8)-positive isolates, all 16 patients had undergone various surgical procedures, and 15 patients had been admitted to the surgical intensive care unit, suggesting a nosocomial outbreak. Two major patterns were observed by pulsed-field gel electrophoresis for 14 of the 17 nonrepetitive isolates, indicating that the clonal spread was mainly responsible for the outbreak.

Adult↗

Evaluation of VITEK 2 rapid identification and susceptibility testing system against gram-negative clinical isolates.

A total of 281 strains of miscellaneous members of the family Enterobacteriaceae, Pseudomonas aeruginosa, and other gram-negative bacteria were evaluated by use of identification tests with the VITEK 2 system (bioMérieux) and an API identification system (bioMérieux). A total of 237 (95%) strains were correctly identified to the species level. Only six (2.1%) strains were misidentified, and eight (2.8%) strains were not identified. Among 14 strains with discrepant identifications, 8 (57.1%) strains were nonfermenters. The susceptibilities of 228 strains to 11 antibiotics including amikacin, netilmicin, tobramycin, gentamicin, ciprofloxacin, imipenem, meropenem, ceftazidime, cefepime, piperacillin, and piperacillin in combination with tazobactam were tested with the VITEK 2 AST-No. 12 card and by the broth microdilution (MB) method, according to NCCLS guidelines, as a reference. For the 2,508 organism-antibiotic combinations, the rates at which duplicate MICs correlated within +/-1 dilution ranged from 84.2 to 95.6%. Only 13 (0.5%) and 10 (0.4%) of the susceptibility tests gave major errors (resistant with the VITEK 2 system but sensitive by the MB method) and very major errors (sensitive with the VITEK 2 system but resistant by the MB method), respectively. Both VITEK 2 ID-GNB (an identification system) and VITEK 2 AST-No. 12 (a susceptibility testing system) card systems gave rapid, reliable, and highly reproducible results.

Anti-Bacterial Agents↗

In vitro susceptibilities of the Bacteroides fragilis group species: change in isolation rates significantly affects overall susceptibility data.

A comparison of antimicrobial susceptibility data of species of the Bacteroides fragilis group for 1989-1990 and 1998-1999 studies showed statistically significant increases or decreases in in vitro activity. Overall significant increases in resistance were noted for ampicillin-sulbactam and clindamycin, while significant decreases in resistance were noted for ertapenem and cefoxitin. Susceptibilities to piperacillin-tazobactam, imipenem, meropenem, and trovafloxacin remained virtually the same for the two studies. Importantly, a change in the rates of isolation of the various species showed the B. fragilis species comprised 58% of the isolates in 1989 to 1990 and 45% of the isolates in 1998 to 1999. This change in rates of isolation of B. fragilis versus non-B. fragilis species had an overall effect on susceptibility data.

Anti-Bacterial Agents↗

Epidemiology and antimicrobial susceptibilities of 111 Campylobacter fetus subsp. fetus strains isolated in Québec, Canada, from 1983 to 2000.

The epidemiology and antimicrobial susceptibilities of 111 Campylobacter fetus subsp. fetus strains isolated from 103 patients from 1983 to 2000 in Québec, Canada, were determined. The median number of patients infected annually with this bacteria was seven, with an incidence of 0.1 per 100,000 population. The male-to-female ratio was 1.1 to 1.0. The patients originated from 13 of the 18 Québec socioeconomic regions. The age range of the patients was 6 months to 90 years old, 53% being > or = 70 years old and 2% being <20 years old. The isolation site was blood for 69% of the patients, stools for 20%, and other body fluids for 11% of them. Three patients suffered a relapse, with the same strain being isolated from the same site at different times as confirmed by pulse-field gel electrophoresis. All isolates were susceptible to ampicillin, gentamicin, meropenem, and imipenem, with 90% minimal inhibitory concentrations of 4, 1, 0.12, and < or = 0.06 microg/ml, respectively. Three percent and two percent of the strains were, respectively, resistant and intermediate to ciprofloxacin. Thirty-four percent of the strains were resistant to tetracycline. There was a nonsignificant increase in resistance to ciprofloxacin (P = 0.27) and to tetracycline (P = 0.65) in recent years. The percentages of intermediate and resistant MICs were, respectively, 12 and 1% for cefotaxime and 71 and 0% for erythromycin. All strains were beta-lactamase negative.

Anti-Bacterial Agents↗

Evaluation of the VITEK 2 system for rapid direct identification and susceptibility testing of gram-negative bacilli from positive blood cultures.

This study explores the possibility of combining the BacT/Alert Microbial Detection System with the VITEK 2 system to achieve rapid bacterial identification and susceptibility testing. Direct inoculation of bacterial suspension to the VITEK 2 ID-GNB card and AST-NO09 card was made by differential centrifugation of blood cultures of organisms with gram-negative enteric bacillus-like morphology. A total of 118 strains were investigated; of these, 97 (82.2%) strains were correctly identified to the species level and 21 (17.8%) strains were not identified; by comparing the results with those of the reference method of API identification systems using a pure culture, it was found that no strain had been misidentified. Among the 21 strains with no identification, 13 (61.9%) strains were nonfermenters. The direct-identification reporting time of VITEK 2 was 3.3 h. Direct testing of susceptibility to 11 antibiotics, i.e., amikacin, cefepime, ceftazidime, ciprofloxacin, gentamicin, imipenem, meropenem, netilmicin, piperacillin, piperacillin-tazobactam, and tobramycin, was also performed by using the broth microdilution (MB) method according to the NCCLS guidelines as a reference. After comparing the MICs of the VITEK 2 system with those obtained by the MB method within +/-twofold dilution, it was determined that the 1,067 organism-antibiotic combinations had an overall correct rate of 97.6% (1,041 combinations). The rates of susceptibility to the 11 antibiotics ranged from 88.7 to 100%, respectively. Only two (0.2%) and four (0.4%) combinations of the susceptibility tests gave very major errors (i.e., reported as sensitive by the VITEK 2 system but shown to be resistant by the MB method) and major errors (i.e., reported as resistant by the VITEK 2 system but shown to be sensitive by the MB method), respectively. The reporting time for the direct testing of susceptibility against the 11 antibiotics for 97 blood culture isolates by the VITEK 2 system ranged from 3.3 to 17.5 h. Compared with conventional methods that require 1 or 2 days, this method can make same-day reporting possible and thus permit better patient management.

Anti-Bacterial Agents↗

Quality control for beta-lactam susceptibility testing with a well-defined collection of Enterobacteriaceae and Pseudomonas aeruginosa strains in Spain.

Eighteen Enterobacteriaceae and Pseudomonas aeruginosa strains, 16 of them with well-defined beta-lactam resistance mechanisms, were sent to 52 Spanish microbiology laboratories. Interpretative categories for 8 extended-spectrum beta-lactams were collected. Participating laboratories used their own routine susceptibility testing procedures (88% automatic systems, 10% disk diffusion, and 2% agar dilution). Control results were established by two independent reference laboratories by applying the NCCLS microdilution method and interpretative criteria. Interpretative discrepancies were observed in 16% of the results (4.4% for cefepime, 3.0% for aztreonam, 2.8% for piperacillin-tazobactam, 1.7% for cefotaxime [CTX] and ceftazidime, 1.1% for ceftriaxone, 0.9% for meropenem, and 0.3% for imipenem). High consistency with reference values (<5% of major plus very major errors) was observed with (i) American Type Culture Collection quality control strains; (ii) strains with low-efficiency mechanisms inactivating extended-spectrum beta-lactams, such as OXA-1-producing Escherichiacoli or SHV-1-hyperproducing Klebsiella pneumoniae; (iii) strains with highly efficient mechanisms, such as SHV-5 porin-deficient K. pneumoniae, CTX-M-10 in Enterobacter cloacae hyperproducing AmpC, and P. aeruginosa with the MexAB OprM efflux phenotype or hyperproducing AmpC. Low consistency (>30% major plus very major errors) was detected in K1-producing Klebsiella oxytoca, CTX-M-9-producing E. coli, and in OprD(-) P. aeruginosa strains. Extended-spectrum beta-lactamase (ESBL)-producing strains accounted for 86% of very major errors. Recognition of the ESBL phenotype was particularly low in Enterobacter cloacae strains (<35%), due to the lack of NCCLS-specific rules in this genus. A K1-producing K. oxytoca was misidentified by 10% of laboratories as an ESBL producer. The use of well-defined resistant strains is useful for improving proficiency in susceptibility testing in clinical laboratories.

Anti-Bacterial Agents↗

Emergence of rifampin-resistant Rhodococcus equi with several types of mutations in the rpoB gene among AIDS patients in northern Thailand.

The antimicrobial susceptibilities of 30 Rhodococcus equi isolates obtained from 30 patients between 1993 and 2001 in northern Thailand were investigated. The MICs showed a tendency toward resistance to various antibiotics but sensitivity to imipenem, minocycline, vancomycin, and teicoplanin (MICs, </=0.5 micro g/ml) and relative sensitivity to meropenem, clarithromycin, and ciprofloxacin (MICs, </=2 micro g/ml). Of the 30 isolates, 26 were susceptible (MICs, </=1 micro g/ml), 1 showed low-level resistance (MIC, 8 micro g/ml), and 3 showed high-level resistance (MICs, >/=64 micro g/ml) to rifampin. PCR amplification and DNA sequencing of the rpoB gene and molecular typing by pulsed-field gel electrophoresis (PFGE) were performed for eight R. equi isolates from eight AIDS patients with pneumonia or lung abscess caused by R. equi between 1998 and 2001, including one low- and three high-level rifampin-resistant isolates. As a result, two high-level rifampin-resistant strains with PFGE pattern A had a Ser531Trp (Escherichia coli numbering) mutation, and one high-level rifampin-resistant strain with PFGE pattern B had a His526Tyr mutation, whereas one low-level rifampin-resistant strain with PFGE pattern C had a Ser509Pro mutation. Four rifampin-susceptible strains with PFGE patterns D and E showed an absence of mutation in the rpoB region. Our results indicate the presence of several types of rifampin-resistant R. equi strains among AIDS patients in northern Thailand.

AIDS-Related Opportunistic Infections↗

Phenotypic description and antimicrobial susceptibilities of Aerococcus sanguinicola isolates from human clinical samples.

This report describes the clinical sources and phenotypic characterization of 16 isolates of Aerococcus sanguinicola. Sixteen conventional tests were used to describe and differentiate the 16 isolates of A. sanguinicola from 30 strains of Aerococcus viridans, 27 strains of Aerococcus urinae, and a single strain each of Aerococcus christensenii and Aerococcus urinaehominis. The phenotypic characterizations of the type strains for each species and 14 A. sanguinicola isolates were also compared in the two reference laboratories. A. sanguinicola are catalase-negative, vancomycin-susceptible, gram-positive cocci arranged in clusters and tetrads, as are all Aerococcus species except A. christensenii (which is arranged in short chains). All 16 isolates of A. sanguinicola were leucine aminopeptidase and pyrrolidonylarylamidase positive, which is unique to this species among the aerococci. All A. sanguinicola isolates grew in broth containing 6.5% NaCl, hydrolyzed hippurate, and were variable in the bile-esculin test. None of the isolates deaminated arginine or were Voges-Proskauer positive. The type strain of A. sanguinicola was isolated from a blood culture of a patient living in Denmark. Seven additional isolates were from patients living in Canada, all with urinary tract infections (six were female). Eight isolates were from patients living in five different states in the United States; five were from patients with urinary tract infections, and three were from blood cultures of one patient each with pneumonia, suspected endocarditis, and unknown clinical conditions. The antimicrobial susceptibility patterns were unremarkable; all isolates tested were susceptible to penicillin, amoxicillin, cefotaxime, cefuroxime, erythromycin, chloramphenicol, vancomycin, quinupristin-dalfopristin (Synercid), rifampin, linezolid, and tetracycline. Six of the 15 cultures were resistant to ciprofloxacin and levofloxacin, but all 15 strains were susceptible to sparfloxacin. High-level resistance was detected for meropenem (2 strains) and trimethoprim-sulfamethonazole (1 strain). Intermediate resistance was detected for trimethoprim-sulfamethoxazole (10 strains) and clindamycin (3 strains).

Anti-Bacterial Agents↗

Bacillus cereus bacteremia in a preterm neonate.

Bacillus cereus is an uncommon but potentially serious bacterial pathogen causing infections of the bloodstream, lungs, and central nervous system of preterm neonates. A case of bacteremia caused by B. cereus in a 19-day-old preterm neonate who was successfully treated with vancomycin, tobramycin, meropenem, and clindamycin is described. Implications for the diagnostic laboratory and clinicians when Bacillus species are detected in normally sterile sites are discussed, and the small numbers of infant infections proven to be due to this organism that have been described previously are reviewed.

Anti-Bacterial Agents↗

Catheter-related bloodstream infection caused by Mycobacterium brumae.

Mycobacterium brumae is a rapidly growing environmental mycobacterial species identified in 1993; so far, no infections by this organism have been reported. Here we present a catheter-related M. brumae bloodstream infection in a 54-year-old woman with breast cancer. The patient presented with high fever (39.7 degrees C), and >1,000 colonies of M. brumae grew from a quantitative culture of blood drawn through the catheter. A paired peripheral blood culture was negative, however, suggesting circulational control of the infection. The patient was treated empirically with meropenem and vancomycin, and the fever resolved within 24 h. The catheter was removed a week later, and from the tip M. brumae was isolated a second time, suggesting catheter colonization. The organism was identified by colonial morphology, sequence analysis of the 16S rRNA gene, and biochemical tests.

Bacteremia↗

Clinically feasible biofilm susceptibility assay for isolates of Pseudomonas aeruginosa from patients with cystic fibrosis.

Pseudomonas aeruginosa is the predominant cause of chronic airway infection in cystic fibrosis (CF). CF airway isolates are often tested for antibiotic susceptibility but are rarely eradicated by the antibiotics identified as potentially effective. The growth state of P. aeruginosa in CF airways is probably different from that exhibited under conventional susceptibility testing conditions and may represent a bacterial biofilm. Biofilm susceptibility testing methods were adapted to create an assay for implementation in a clinical microbiology laboratory. This assay gave reproducible results when examined in 300 paired determinations with 12 antimicrobial agents, with a serious error rate of 5.7%. The biofilm assay was used retrospectively to test these 12 agents against 94 isolates from 41 CF patients. The biofilm inhibitory concentrations (BICs) were much higher than the corresponding conventionally determined MICs for the beta-lactam antibiotics (median values: aztreonam, >128 microg/ml versus 4 microg/ml; ceftazidime, 128 microg/ml versus 2 microg/ml; piperacillin-tazobactam, 256 microg/ml versus 4 microg/ml; and ticarcillin-clavulanate, 512 microg/ml versus 16 microg/ml, respectively) and doxycycline (>64 microg/ml versus 16 microg/ml); and similar for meropenem (4 micro g/ml versus < or = 1 microg/ml), ciprofloxacin (0.5 microg/ml versus 1 microg/ml), and the aminoglycosides amikacin (32 microg/ml versus 16 microg/ml), gentamicin (16 microg/ml versus 8 microg/ml), and tobramycin (4 microg/ml versus 2 microg/ml). The median BIC for azithromycin was 2 microg/ml, whereas isolates were uniformly resistant when tested by standard methods. This demonstrates the feasibility of adapting biofilm susceptibility methods to the clinical microbiology laboratory and opens the way to examining whether biofilm testing might be used to select more effective antibiotic combinations for CF airway infections than methods in current use.

Bacteriological Techniques↗