An outbreak of Mycobacterium jacuzzii infection following insertion of breast implants

BACKGROUND

Surgical wound infections caused by rapidly growing mycobacteria developed in 15 women after insertion of breast implants from August to November 2003 at a single medical center.

METHODS

A case-control study was conducted that included the identified patients, as well as women who underwent breast operations at the same center who did not develop infections. The study was accompanied by an extensive environmental investigation. Isolates were identified by standard bacteriological methods and by comparison of their 16S rRNA, HSP65, RPOB, SODA, and RECA gene sequences. Isolates were compared by random amplified polymorphic DNA analysis and by pulsed-field gel electrophoresis.

RESULTS

The risk factors for infection included surgery performed by 1 specific surgeon (odds ratio, 21.3; 95% confidence interval, 3.64-125.6). Identical strains of mycobacteria were isolated from the infected wounds of the patients; from the eyebrows, hair, face, nose, ears, and groin of this particular surgeon; and from this surgeon's outdoor whirlpool. The isolates exhibited a biochemical profile overlapping that of Mycobacterium wolinskyi, but their sequences of 16S rRNA and HSP65, RPOB, SODA, and RECA genes differed. We propose the name "Mycobacterium jacuzzii" for this new species. DNA fingerprints of cultured isolates from the surgical wounds, areas of the surgeon's body that grow hair, and the surgeon's whirlpool were identical. When the surgeon discontinued his use of the whirlpool and began cleaning the hairy areas of his body with a shampoo containing triclosan, the outbreak ended.

CONCLUSIONS

This outbreak brings to light the possibility of the colonization of human skin and human-to-human transmission of environmental mycobacteria during surgery that involves implant insertion.

Methicillin-resistant Staphylococcus aureus in neonatal intensive care unit

A neonatal intensive care unit outbreak was caused by a strain of methicillin-resistant Staphylococcus aureus previously found in the community (ST45-MRSA-IV). Fifteen infected neonates were identified, 2 of whom died. This outbreak illustrates how a rare community pathogen can rapidly spread through nosocomial transmission.

Excision of nucleoside analogs from DNA by p53 protein, a potential cellular mechanism of resistance to inhibitors of human immunodeficiency virus type 1 reverse transcriptase

We investigated the ability of p53 in cytoplasm to excise nucleoside analogs (NAs). A decrease in incorporation of NAs by human immunodeficiency virus type 1 reverse transcriptase and their excision from DNA by p53, provided by the cytoplasmic fraction of LCC2 cells, suggest that p53 in cytoplasm may act as an external proofreader for NA incorporation.

An Outbreak of Phialemonium Infective Endocarditis Linked to Intracavernous Penile Injections for the Treatment of Impotence

BACKGROUND

In March 2002, a patient in Tel Aviv, Israel, died of endocarditis caused by Phialemonium curvatum. As part of his therapy for erectile dysfunction, the patient had been trained to self-inject a compound of vasoactive drugs provided by an impotence clinic into his penile corpus cavernosous.

METHODS

We identified the used prefilled syringes as the source of his infection. Similar cases were investigated as a putative outbreak of P. curvatum invasive disease among customers of this impotence clinic. P. curvatum isolates, cultured from samples obtained from the patients and from prefilled syringes, were compared by DNA sequencing of the nuclear ribosomal internal transcribed spacer.

RESULTS

We identified 2 additional customers at the impotence clinic who had P. curvatum endocarditis. In addition, cultures of unused, prefilled syringes and bottles provided by the same clinic to 5 asymptomatic customers tested positive for pathogenic molds (P. curvatum in 4 cases and Paecilomyces lilacinus in 1). All P. curvatum isolates were of a single genetic type that is known only from this outbreak but is closely related to 3 other P. curvatum genotypes associated with pathogenicity in humans.

CONCLUSIONS

P. curvatum is an emerging pathogen that can be readily isolated from blood. We identified an outbreak of P. curvatum endocarditis among men who had erectile dysfunction treated by intracavernous penile injections from contaminated prefilled syringes.

The fidelity of DNA synthesis by human immunodeficiency virus type 1 reverse transcriptase increases in the presence of polyamines

The high error rates characteristic of human immunodeficiency virus type-1 reverse transcriptase (HIV-1 RT) are a presumptive source of the viral hypervariability that substantially affect viral pathogenesis and resistance to drug therapy. We have analyzed the potential role of polyamines in the fidelity of DNA synthesis by HIV-1 RT. The current study suggest that polyamines tested has the potential to be "antimutator". The polyamines exert the ability to reduce the misincorporation and mispair extension with both RNA/DNA and DNA/DNA template-primers in the following order: spermine > spermidine > putrescine. In view of the significance of mutations of HIV, the possible roles of polyamines in the accuracy of DNA synthesis could be of particular importance; polyamines may affect the mutation rate of the virus.

Association between carriage of Streptococcus pneumoniae and Staphylococcus aureus in Children

CONTEXT

Widespread pneumococcal conjugate vaccination may bring about epidemiologic changes in upper respiratory tract flora of children. Of particular significance may be an interaction between Streptococcus pneumoniae and Staphylococcus aureus, in view of the recent emergence of community-acquired methicillin-resistant S aureus.

OBJECTIVE

To examine the prevalence and risk factors of carriage of S pneumoniae and S aureus in the prevaccination era in young children.

DESIGN, SETTING, AND PATIENTS

Cross-sectional surveillance study of nasopharyngeal carriage of S pneumoniae and nasal carriage of S aureus by 790 children aged 40 months or younger seen at primary care clinics in central Israel during February 2002.

MAIN OUTCOME MEASURES

Carriage rates of S pneumoniae (by serotype) and S aureus; risk factors associated with carriage of each pathogen.

RESULTS

Among 790 children screened, 43% carried S pneumoniae and 10% carried S aureus. Staphylococcus aureus carriage among S pneumoniae carriers was 6.5% vs 12.9% in S pneumoniae noncarriers. Streptococcus pneumoniae carriage among S aureus carriers was 27.5% vs 44.8% in S aureus noncarriers. Only 2.8% carried both pathogens concomitantly vs 4.3% expected dual carriage (P =.03). Risk factors for S pneumoniae carriage (attending day care, having young siblings, and age older than 3 months) were negatively associated with S aureus carriage.

CONCLUSIONS

Streptococcus pneumoniae carriage, specifically of vaccine-type strains, is negatively associated with S aureus carriage in children. The implications of these findings in the pneumococcal vaccine era require further investigation.

Azithromycin versus comparative therapy for the treatment of community acquired pneumonia

A 3-day course of azithromycin was compared with the 10 days of other antibiotics, which general practitioners routinely use as therapy for community acquired pneumonia (CAP). The study was a prospective open labelled, randomised, multicentre, comparative study from five family clinics. Patients with clinical and radiological evidence of pneumonia were included. The pneumonia resolved in 98.4% (61/62) of patients treated with azithromycin and in 87% (40/46) of patients treated with other antibiotics (P < 0.017). Restitution of normal function at home (2.3 +/- 1.2 and 4.3 +/- 2.6 days) and return to work (3.4 +/- 2.0 and 5.5 +/- 3.1 days) was more rapid among the group treated with azithromycin ( P < 0.001). Three days of azithromycin was more convenient and cost effective than the comparators used to treat pneumonia.

Helicobacter pylori DNA in dental plaques, gastroscopy, and dental devices

The role of dental plaque in the transmission of Helicobacter pylori (Hp) is unclear due to variability in the detection rates and techniques used. We used nested PCR to estimate the incidence of Hp in dental plaques of 24 dental hygienists. We found an unexpectedly high incidence (50%) of Hp DNA in dental plaques using sterilized dental probes. Additional treatment of sonication and SDS wash prior to sterilization of dental probes reduced the incidence to 13%. We used the treated probes to assess Hp presence in plaque samples of 47 patients visiting the dental clinic for teeth cleaning. Hp DNA was detected in 24% of cases. Since these data may reflect instrument contamination, we tested dental probes, endoscopes, and endoscopy forceps and found that 12.5-37.5% of them were contaminated. Consequently, dental plaques may be a candidate reservoir for Hp, medical equipment may contribute to Hp transmission, and sample collection techniques can bias the true prevalence of Hp in a population.

Type II topoisomerase mutations in Bacillus anthracis associated with high-level fluoroquinolone resistance

OBJECTIVES

To identify and characterize the mechanisms of high-level fluoroquinolone resistance in two strains of Bacillus anthracis following serial passage in increasing concentrations of fluoroquinolones.

METHODS

Fluoroquinolone-resistant isolates of the Sterne and Russian Anthrax Vaccine STi strains were obtained following serial passage in the presence of increasing concentrations of four different fluoroquinolones. The quinolone-resistance-determining regions of the type II topoisomerase genes from the resistant strains were amplified by PCR and characterized by DNA sequence analysis. The MICs in the presence and absence of reserpine were determined using broth microdilution as a means of detecting active efflux.

RESULTS

Single and double amino acid substitutions in the GyrA (Ser-85-Leu; Glu-89-Arg/Gly/Lys) and GrlA (Ser-81-Tyr; Val-96-Ala; Asn-70-Lys) were most common. A single amino acid substitution in GyrB (Asp-430-Asn) was also identified. Efflux only applied to isolates selected for by either levofloxacin or ofloxacin.

CONCLUSIONS

Specific amino acid substitutions in the type II topoisomerase enzymes significantly contributed to the development of high-level fluoroquinolone resistance in B. anthracis. However, notable differences between the strains and the drugs tested were identified including the role of efflux and the numbers and types of mutations identified.

Molecular epidemiology of asymptomatic bacteriuria in the elderly

OBJECTIVES

to determine the incidence and the dynamics of asymptomatic bacteriuria in ambulatory nursing home residents, and to characterise bacteria according to their phenotype and genotype.

DESIGN

an 18 months prospective longitudinal study.

SUBJECTS

42 nursing home residents (31 female, 11 males) without indwelling catheters.

METHODS

urine was sampled every 3 months. Antibiograms, biotyping and ribotyping were performed.

RESULTS

the cumulative percent of infection for females and males was 75% and 27% respectively. Osteoporosis was associated with bacteriuria. Ribotypes of consecutive Escherichia coli isolates indicated that each patient harboured a different strain.

CONCLUSIONS

asymptomatic bacteriuria in the elderly is a dynamic and transient phenomenon. Osteoporosis is common among this population. Ribotyping is a powerful tool in the elucidation of the epidemiology of this bacteriuria.

[Severe acute respiratory syndrome (SARS)]

On November 2002, 305 cases of atypical pneumonia appeared in southern China. In February 2003, cases were reported in Hong Kong and from there the disease spread to many other countries, mainly, China, Hong Kong, Singapore, Vietnam and Toronto in Canada. The syndrome was defined as Severe Acute Respiratory Syndrome SARS), and a person is suspected of having SARS if he/she became ill after November 1 2002, has a fever exceeding 38 degrees C, has symptoms of a respiratory disease and was in a risk area or in close contact with a SARS patient within ten days prior the appearance of symptoms. The World Health Organization has received reports of 4,836 cases, of which 293 persons have died. Most were family members or medical staff treating the patient, persons who came into close and prolonged contact with the patient. The estimated incubation period is two days to one week. Symptoms of the disease include fever, shortness of breath and cough. Ten percent of patients afflicted with SARS require artificial breathing. The mortality rate is 6-7%. A novel coronavirus is associated with this outbreak, and the evidence indicates that this virus has an etiologic role in SARS. Infection is transmitted from person to person through direct or close contact with airborne droplets or personal objects of an infected person. Patients must be isolated and treated by contact and airborne isolation. Treatment consists of support care and artificial respiration when required. The use of anti-viral medications has not yet proven effective.

Brucella prosthetic joint infection: a report of 3 cases and a review of the literature

We report 3 cases of Brucella melitensis infection of prosthetic hips and knees, and we summarize data about 4 cases reported in the literature. Six of the 7 affected patients were men. The median duration from prosthesis implantation to the onset of symptoms was 38.7 months. Five patients had only local symptoms. Preoperative joint aspirates yielded negative culture results for 3 patients, and blood culture results were negative for 6 patients. Excisional arthroplasty was the initial intervention for 3 patients. Three others responded well to medical therapy alone. One patient had relapse while receiving tetracycline and underwent total hip replacement. All patients were treated with combined antibiotic therapy for 6 weeks to 19 months. All had favorable long-term responses. The 3 patients we treated underwent a 2-staged resection arthroplasty. Antibiotics alone can be used to treat Brucella prosthetic joint infection, but loosening of the joint and clinical or microbiological failure must be treated with a 2-staged excisional arthroplasty and 3 months of treatment with doxycycline and rifampicin.

Listeria infection during pregnancy: a 10 year experience

BACKGROUND

Although Listeria monocytogenes is widely distributed in nature, it rarely causes clinical infection in previously healthy people. This microorganism, however, may cause severe invasive disease in pregnant women and newborns.

OBJECTIVES

To investigate--in our pregnant population--the impact, severity and outcome of listeriosis on both mother and fetus.

METHOD

The study was carried out at a level III, university two-hospital complex. In a retrospective chart review of 65,022 parturients during a 10 year period (1990-1999), we identified and evaluated 11 pregnant patients and their offspring with Listeria infection.

RESULTS

Chorioamnionitis with multiple placental abscesses were observed in all five placentae examined. Clinically, 4 of 11 parturients had a cesarean section for fetal distress (36.3%), as compared to the 14% mean CS rate in our general population. Two of 11 had a late abortion (18.1%), as compared with the 4% rate in our hospital. Four of 11 had premature labor (36%), which was about four times the rate in our population. Finally, although no intrauterine fetal death was recorded in our series, there was one neonatal death of a term infant (1/11, 9%), which is about 10 times higher than our corrected perinatal mortality rate.

CONCLUSIONS

If not promptly and adequately treated, listeriosis in pregnancy may present serious hazards to the fetus and newborn through direct infection of the placenta and chorioamnionitis.

Listeria monocytogenes infection in Israel and review of cases worldwide

Listeria monocytogenes, an uncommon foodborne pathogen, is increasingly recognized as a cause of life-threatening disease. A marked increase in reported cases of listeriosis during 1998 motivated a retrospective nationwide survey of the infection in Israel. From 1995 to 1999, 161 cases were identified; 70 (43%) were perinatal infections, with a fetal mortality rate of 45%. Most (74%) of the 91 nonperinatal infections involved immunocompromised patients with malignancies, chronic liver disease, chronic renal failure, or diabetes mellitus. The common clinical syndromes in these patients were primary bacteremia (47%) and meningitis (28%). The crude case-fatality rate in this group was 38%, with a higher death rate in immunocompromised patients.

Alcohol drinking patterns among Jewish and Arab men and women in Israel

OBJECTIVE

Jews and Muslim Arabs comprise the bulk of modern Israeli society. Jewish tradition permits controlled alcohol drinking, whereas Muslim tradition prohibits the use of any alcohol. Increasing exposure of the traditionally conservative Arab sector to the Western culture of modern Israel might impact on and be reflected in the drinking patterns of these two populations. The influence of religiosity and other factors on drinking patterns of Jewish and Arab adults are examined using data from a 1995 national household survey.

METHOD

Past month drinking is assessed in this nationally representative sample of nearly 5,000 Jews and 1,000 Arabs (N = 5,954, 60% women). Unadjusted and adjusted odds ratios (ORs) are presented to describe associations between any and heavy drinking and nationality group, religiosity, education and marital status among men and women. Modification of the nationality-drinking relationship by religiosity is also examined.

RESULTS

Any past-month drinking was reported more often by Jewish respondents than Arab respondents (OR = 2.9, 95% Cl: 2.5-3.4), and this difference remained statistically significant after accounting for the effects of the other covariables. This cross-nationality difference was more pronounced among women (OR = 6.4, 95% Cl: 4.6-8.8) than men (OR = 2.3, 95% CI: 1.8-2.9). The proportion of drinkers who reported heavy drinking in the past month, however, was lower among Jews (OR = 0.3, 95% CI: 0.2-0.4). Significantly higher rates of drinking were noted for secular men and women than for religious respondents in both nationality groups. Rates of drinking were more similar among secular Arabs and Jews than among religious respondents of these nationality groups.

CONCLUSIONS

These results add support to the theory that adherence to religious traditions continues to serve as a barrier against drinking among both Arabs and Jews. Further work is required to determine if these patterns are stable over time and whether genetic factors are contributing to the sociocultural influences.

Differences in drinking patterns among Ashkenazic and Sephardic Israeli adults

OBJECTIVE

Since its foundation in 1948, Israel has received large waves of immigrants, mainly from Europe (Ashkenazic Jews, or Ashkenazim) and from North Africa and other Middle Eastern countries (Sephardic Jews. or Sephardim). In Israeli society, Ashkenazic Jews are an advantaged ethnic group, whereas Sephardic Jews are relatively disadvantaged. Little is known about the differences in drinking patterns between these two groups. The relationship between ethnicity and alcohol consumption is investigated in a 1995 data set from a sample of 4,984 subjects (60% women).

METHOD

The data were collected as part of a national Israeli survey. Standardized questions covered drinking and becoming drunk in the last 12 months and drinking in the last 30 days. Unadjusted odds ratios (ORs) indicated the association of group status with the drinking variables. ORs adjusted for potential confounders were created with logistic regression.

RESULTS

Unadjusted ORs indicated a negative association between all alcohol measures and Sephardic group status. ORs adjusted for such factors as socioeconomic status and religiosity produced similar results.

CONCLUSIONS

This study indicates that Sephardim were less likely to drink or become drunk than were Ashkenazim. Further work is required to determine if these differences are stable or changing over time and whether such differences can be attributed to cultural or genetic factors. Similarities to U.S. patterns are discussed.

Molecular epidemiology of Mycobacterium tuberculosis infection in Israel

Restriction fragment length polymorphism analysis with IS6110 and DR-r probes was used to study 69 Mycobacterium tuberculosis isolates obtained from Israeli patients and new immigrants from the former Soviet Union and Ethiopia. DNA fingerprinting identified unique patterns for almost all isolates, indicating that most patients were infected with a unique strain imported from their country of origin and that their latent infection was reactivated in Israel.

Skin disease presenting as an outbreak of pseudobacteremia in a laboratory worker

An outbreak of pseudobacteremia due to Streptococcus pyogenes (group A streptococci [GAS]) and methicillin-susceptible Staphylococcus aureus (MSSA) was traced to the venting procedure for aerobic bottles prior to their loading into the incubator of the BacT/Alert analyzer (Organon Teknika). Bacteria shed by a laboratory worker suffering from impetigo and cellulitis contaminated the aerobic bottles of 10 patients. All blood culture isolates, in addition to the isolates from the laboratory worker, were of the same GAS M and T types. All MSSA isolates from blood cultures and the index case's hands had the same lytic phage profile. Procedural breakdowns were identified in the laboratory. Bottles were vented outside the biological safety cabinet, gloves were not worn, and unprotected needles were used for the venting procedure. The source of the aspirated bacteria that contaminated the bottles was identified and the index case was treated promptly.

Acinetobacter baumannii at a tertiary-care teaching hospital in Jerusalem, Israel

In a retrospective 10-year analysis of 3,536 patient-unique isolates, Acinetobacter baumannii imipenem susceptibility declined from 98.1 (1990) to 64.1% (2000), and ciprofloxacin susceptibility decreased from 50.5 to 13.1%. Imipenem median zone diameters decreased from 27. 7 (1997) to 18.8 mm (2000). No outbreaks were detected. Two clusters were identified for 41 strains genotyped by pulsed-field gel electrophoresis, but imipenem resistance was not clonal.

The drinking of earlier and more recent Russian immigrants to Israel: comparison to other Israelis

OBJECTIVES

Russia has a high level of per capita alcohol consumption, while the level in Israel is low. Since 1989, over 820,000 Russian Jews immigrated to Israel. In the 1970's and early 1980's, a smaller wave of immigration from Russia to Israel occurred (approximately 170,000). The drinking of earlier immigrants was compared to recent immigrants and other Israelis.

METHODS

Data came from a 1995 national survey of Israeli household residents. Of 4984 Israeli respondents, 292 were Russian immigrants who arrived since 1989 and 131 were Russians who immigrated earlier. Groups were compared with logistic regression.

RESULTS

Recent Russian immigrants were more likely to drink in the last 12 months, to drink frequently and to get drunk than other Israelis. The earlier Russian immigrants were not more likely than other Israelis to report drinking in the last 12 months or frequent drinking, but were more likely to report 30-day drinking and getting drunk. In direct comparison of recent and earlier Russians, recent immigrants reported more frequent drinking than earlier immigrants.

CONCLUSIONS

The results for drinking and frequency of drinking are consistent with acculturation effects as well as other explanations. Further investigation in studies with appropriate designs will be necessary to clarify the meaning of these results.

Gender differences in alcohol consumption and adverse drinking consequences: cross-cultural patterns

AIMS

To examine the consistency and/or variability of gender differences in drinking behavior cross-culturally.

DESIGN, SETTING, PARTICIPANTS

Women's and men's responses in 16 general population surveys from 10 countries, analyzed by members of the International Research Group on Gender and Alcohol.

MEASUREMENTS

Comparable measures of drinking, versus abstention, typical drinking frequencies and quantities, heavy episodic drinking, intoxication, morning drinking, and alcohol-related family and occupational problems.

FINDINGS

Women and men differed little in the probability of currently drinking versus abstaining, but men consistently exceeded women in typical drinking frequencies and quantities and in rates of heavy drinking episodes and adverse drinking consequences, while women were consistently more likely than men to be life-time abstainers. In older age groups, both men and women drank smaller quantities of alcohol and were more likely to stop drinking altogether, but drinking frequencies did not change consistently with age.

CONCLUSIONS

A theoretical synthesis proposes that gender roles may amplify biological differences in reactions to alcohol, and that gender differences in drinking behavior may be modified by macrosocial factors that modify gender role contrasts.

Drinking patterns of recent Russian immigrants and other Israelis: 1995 national survey results

OBJECTIVES

A large group of Russian Jews has immigrated to Israel since 1989. Russia has one of the highest alcohol consumption levels in the world, while the level in Israel is among the lowest. This study was designed to provide empirical information on the drinking of these Russian immigrants compared with the drinking of other Jewish Israeli residents.

METHODS

The data came from a 1995 national survey of drinking in Israel. Of 4984 Israelis, 292 were Russian immigrants who had arrived since 1989. Russians were compared with other respondents on several drinking variables. Logistic regression was the principal method of analysis, allowing the relationship to be tested with demographic and cultural variables controlled. A subsidiary analysis was conducted on data about parents' drinking from a survey of secondary school students.

RESULTS

There were significant effects for Russian status for several drinking variables, with significant odds ratios ranging from 1.45 to 2.38. These results indicate that recent Russian immigrants to Israel drink more than their Israeli counterparts.

CONCLUSIONS

Further investigation of the stability of these patterns may provide valuable information about cultural effects on drinking.