Tandem repeat analysis for surveillance of human Salmonella Typhimurium infections

Molecular characterization of Salmonella Typhimurium highly successful outbreak strains

Three large clusters of Salmonella Typhimurium infections in Denmark in 2008 and 2009 were defined by multilocus variable number of tandem repeat analysis (MLVA). One of these proved to be the hereto largest Danish cluster of salmonellosis with 1446 cases. Two smaller clusters with a total of 197 and 89 cases, respectively, were seen concurrently. These clusters shared epidemiological characteristics such as age distribution, geography, and time. To investigate the possible genetic relationship between the cluster strains, these were further characterized by phage typing, pulsed-field gel electrophoresis, and Optical Mapping. Although the MLVA method proved robust and well-performing in detecting and defining clusters, the employment of a second typing method detected an additional fourth cluster among the isolates. The cluster strains were stable throughout the almost 2-year period, even though we detected changes in three of five MLVA loci in a small fraction of isolates. These changes were mainly due to the gain or loss of single repeats. Optical Mapping of the large cluster strain indicated no increased content of virulence genes; however, Optical Mapping did reveal a large insert, a probable prophage, in the main cluster. This probable prophage may give the cluster strain a competitive advantage. The molecular methods employed suggested that the four clusters represented four distinct strains, although they seemed to be epidemiologically linked and shared genotypic characteristics.

MLVA and phage typing as complementary tools in the epidemiological investigation of Salmonella enterica serovar Typhimurium clusters

In South Australia serotyping and phage typing are employed for routine Salmonella surveillance. Molecular techniques such as Multiple-locus variable number tandem repeat analysis (MLVA) are increasingly utilized to aid outbreak investigations. During 2007 three Salmonella enterica serovar Typhimurium outbreaks involving phage types DT9, DT29, and DT44 were investigated. Human, food and environmental isolates were also typed by MLVA. In the DT9 outbreak cluster MLVA demonstrated distinct groupings that corresponded to epidemiological differences in time, place, and descriptive information on potential transmission mechanisms. In contrast, the human and food isolates of both the DT29 and DT44 clusters had identical MLVA profiles for all but one case. These data correlated with the epidemiology suggesting that these isolates were closely related and probably a single agent. These findings illustrate that phage typing and MLVA can provide different but complementary information for epidemiological investigations of Salmonella outbreaks.

Multiple-locus variable-number tandem-repeat analysis for discriminating within Salmonella enterica serovar Typhimurium definitive types and investigation of outbreaks

The discriminatory power of multiple-locus variable-number tandem-repeat analysis (MLVA) needs to be evaluated for all Salmonella enterica subspecies enterica serovar Typhimurium (S. Typhimurium) phage types so that the power of this methodology is understood and results can be interpreted correctly during outbreak investigations. We evaluated the ability of MLVA to characterize four definitive phage types (DT) problematic in New Zealand. MLVA discriminated between DT104 isolates although there was very limited variation in the MLVA profiles for isolates with an RDNC phage type (reacts but does not conform to a recognized Typhimurium phage pattern) first observed in New Zealand's Enteric Reference Laboratory in May 2006. Most DT101 isolates had indistinguishable MLVA profiles or profiles that differed at one or two loci. This was also observed in DT160 isolates. MLVA may not identify all common-source outbreaks although it provided valuable data when applied to case isolates from two S. Typhimurium outbreaks.

Improved identification of epidemiologically related strains of Salmonella enterica by use of a fusion algorithm based on pulsed-field gel electrophoresis and multiple-locus variable-number tandem-repeat analysis

Pulsed-field gel electrophoresis (PFGE) and multiple-locus variable-number tandem-repeat analysis (MLVA) are used to assess genetic similarity between bacterial strains. There are cases, however, when neither of these methods quantifies genetic variation at a level of resolution that is well suited for studying the molecular epidemiology of bacterial pathogens. To improve estimates based on these methods, we propose a fusion algorithm that combines the information obtained from both PFGE and MLVA assays to assess epidemiological relationships. This involves generating distance matrices for PFGE data (Dice coefficients) and MLVA data (single-step stepwise-mutation model) and modifying the relative distances using the two different data types. We applied the algorithm to a set of Salmonella enterica serovar Typhimurium isolates collected from a wide range of sampling dates, locations, and host species. All three classification methods (PFGE only, MLVA only, and fusion) produced a similar pattern of clustering relative to groupings of common phage types, with the fusion results being slightly better. We then examined a group of serovar Newport isolates collected over a limited geographic and temporal scale and showed that the fusion of PFGE and MLVA data produced the best discrimination of isolates relative to a collection site (farm). Our analysis shows that the fusion of PFGE and MLVA data provides an improved ability to discriminate epidemiologically related isolates but provides only minor improvement in the discrimination of less related isolates.

The prevalence of multidrug resistance is higher among bovine than human Salmonella enterica serotype Newport, Typhimurium, and 4,5,12:i:- isolates in the United States but differs by serotype and geographic region

Salmonella represents an important zoonotic pathogen worldwide, but the transmission dynamics between humans and animals as well as within animal populations are incompletely understood. We characterized Salmonella isolates from cattle and humans in two geographic regions of the United States, the Pacific Northwest and the Northeast, using three common subtyping methods (pulsed-field gel electrophoresis [PFGE], multilocus variable number of tandem repeat analysis [MLVA], and multilocus sequence typing [MLST]). In addition, we analyzed the distribution of antimicrobial resistance among human and cattle Salmonella isolates from the two study areas and characterized Salmonella persistence on individual dairy farms. For both Salmonella enterica subsp. enterica serotypes Newport and Typhimurium, we found multidrug resistance to be significantly associated with bovine origin of isolates, with the odds of multidrug resistance for Newport isolates from cattle approximately 18 times higher than for Newport isolates from humans. Isolates from the Northwest were significantly more likely to be multidrug resistant than those from the Northeast, and susceptible and resistant isolates appeared to represent distinct Salmonella subtypes. We detected evidence for strain diversification during Salmonella persistence on farms, which included changes in antimicrobial resistance as well as genetic changes manifested in PFGE and MLVA pattern shifts. While discriminatory power was serotype dependent, the combination of PFGE data with either MLVA or resistance typing data consistently allowed for improved subtype discrimination. Our results are consistent with the idea that cattle are an important reservoir of multidrug-resistant Salmonella infections in humans. In addition, the study provides evidence for the value of including antimicrobial resistance data in epidemiological investigations and highlights the benefits and potential problems of combining subtyping methods.

Emergence and characterization of Salmonella enterica serovar Typhimurium phage type DT191a

The emergence of a previously undefined phage type of Salmonella enterica serovar Typhimurium, designated DT191a, occurred in England and Wales in July 2008. The new strain exhibits a number of distinctive phenotypic and genotypic features. This report provides the tools necessary to track S. Typhimurium DT191a globally.

DNA microarray analysis of Salmonella serotype Typhimurium strains causing different symptoms of disease

Background

Salmonella enterica subsp. enterica is one of the leading food-borne pathogens in the USA and European countries. Outcome of human Salmonella serotype Typhimurium infections ranges from mild self-limiting diarrhoea to severe diarrhoea that requires hospitalization. Increased knowledge of the mechanisms that are responsible for causing infection and especially the severity of infection is of high interest.

Results

Strains were selected from patients with mild infections (n = 9) and patients with severe infections (n = 9) and clinical data allowed us to correct for known underlying diseases. Additionally, outbreak isolates (n = 3) were selected. Strains were analyzed on a DNA-DNA microarray for presence or absence of 281 genes covering marker groups of genes related to pathogenicity, phages, antimicrobial resistance, fimbriae, mobility, serotype and metabolism. Strains showed highly similar profiles when comparing virulence associated genes, but differences between strains were detected in the prophage marker group. The Salmonella virulence plasmid was present in 72% of the strains, but presence or absence of the virulence plasmid did not correspond to disease symptoms. A dendrogram clustered strains into four groups. Clustering confirmed DT104 as being a clonal phagetype. Clustering of the remaining strains was mainly correlated to presence or absence of the virulence plasmid and mobile elements such as transposons. Each of the four clusters in the tree represented an almost equal amount of strains causing severe or mild symptoms of infection.

Conclusions

We investigated clinical significance of known virulence factors of Salmonella serotype Typhimurium strains causing different disease symptoms, and conclude that the few detected differences in Salmonella serotype Typhimurium do not affect outcome of human disease.

Epidemiologic study of Vibrio vulnificus infections by using variable number tandem repeats

A 3-year environmental and clinical Vibrio vulnificus survey using simple-sequence repeats typing shows that V. vulnificus biotype 3 constitutes ≈21% of the bacterium population in tested aquaculture ponds as opposed to ≈86% of clinical cases. Simple-sequence repeats proved to be a useful epidemiologic tool, providing information on the environmental source of the pathogen.

Multilocus variable-number tandem-repeat analysis and plasmid profiling to study the occurrence of blaCMY-2 within a pulsed-field gel electrophoresis-defined clade of Salmonella enterica serovar Typhimurium

Salmonella enterica serovar Typhimurium circulating in food animal populations and carrying resistance to antimicrobial agents represents a human health risk. Recently, a new clade of S. Typhimurium, WA-TYP035/187, was reported in cattle and humans in the Pacific Northwest, United States of America. The objective of this study was to describe a possible mechanism of acquisition of expanded-spectrum cephalosporin resistance in this clade. Ceftazidime resistance increased steadily among WA-TYP035/187 isolates, from 0% (0/2) in 1999 to 77.8% (28/36) in 2006 (chi2 for linear trend, P value of <0.001). Among 112 bovine-source and 18 human-source isolates, 49 (43.8%) and 12 (66.7%) were resistant to ceftazidime, respectively. Multiple-locus variable-number tandem-repeat analysis (MLVA) and plasmid profiling suggested that resistance was acquired by multiple independent genetic events within the WA-TYP035/187 clade. Given the lack of an obvious reservoir in species other than cattle and a parallel rise in ceftiofur resistance in the bovine-specific serovar Salmonella enterica serovar Dublin in the same time frame and region, selection pressure due to the use of the expanded-spectrum cephalosporin drug ceftiofur in cattle is a likely factor driving the increasing cephalosporin resistance of WA-TYP035/187.

Drug-resistant Salmonella Typhimurium DT 120: use of PFGE and MLVA in a putative international outbreak investigation

Isolates of Salmonella enterica serovar Typhimurium belonging to definitive phage type (DT) 120 (Salmonella Typhimurium DT 120) from simultaneous outbreaks of infection in the England and Denmark have been compared on the basis of antibiogram, pulsed-field gel electrophoresis (PFGE), and multiple locus variable number tandem repeat analysis (MLVA). Isolates from England had the resistance profile (ampicillin, streptomycin, sulfamethoxazole, and tetracycline), MLVA profiles 2-4-4-0-2, 2-4-5-0-2, and 2-4-0-0-2, and the PFGE type STYMXB.0083. Representative isolates from the Denmark outbreak were resistant to ampicillin only (A) and had the MLVA type 2-12-6-0-2 and the PFGE type STYMXB.0010. These results demonstrated that outbreak isolates from England and Denmark were not identical. Subsequently, comparison of outbreak isolates with contemporary animal isolates showed that an isolate with the same PFGE type and a similar MLVA type had been isolated in England before its identification in Denmark. These results confirmed the usefulness of MLVA in international outbreak investigations of multiresistant Salmonella Typhimurium and have demonstrated how new molecular strategies may be used to supplement existing methods such as PFGE to enable the accurate and rapid comparison of isolates from different countries. The data also indicate that MLVA proves a useful method for detection of specific Salmonella Typhimurium DTs from human and veterinary sources.

Phenotypic characterization of Salmonella typhimurium isolates from food-animals and abattoir drains in Buea, Cameroon

Salmonella spp. have been extensively incriminated worldwide as common causes of bacterial gastroenteritis in humans, with food-animals serving as important reservoirs. The study was aimed at investigating cattle and pigs slaughtered in Buea as reservoirs of Salmonella Typhimurium and the susceptibility of isolates to antibiotics. In total, 230 specimens (comprising 50 each from the rectum, ileum, and gall bladder of cattle; and 10 each from same anatomical sites of pigs and 50 from abattoir drains) were analyzed for Salmonella using the standard microbiological, biochemical and serological techniques. Antibiotic susceptibility of the isolates was determined by the Kirby-Bauer disc-diffusion test. The isolates were characterized into biotypes using the API 20E kit, and results were analyzed using the chi-square test. Seventy-five (32.6%) of the 230 specimens were positive for S. Typhimurium, with pigs and abattoir drains presenting the highest level of isolation (40%). Biochemical typing grouped the isolates into five biotypes. Biotype I was the most prevalent (30.6%) while biotype IV was the least prevalent (9.3%) and was absent in samples from pigs. Antibiotic susceptibility studies revealed 14 antibiotypes based on antibiotics used in the study. The predominant antibiotype AMX DOX CEF was recorded in 13 (17.3%) of the isolates. Multidrug resistance (to four or more antibiotics) was recorded in 50.7% (38/75) of the isolates. The most active drugs were ciprofloxacin (98.6%), ofloxacin (93.3%), amikacin (90.6%), and gentamicin (84%). All the isolates (100%) were resistant to tetracycline and ampicillin. Cattle and pigs were found to be reservoirs of S. Typhimurium in the environment of Buea, Cameroon, implying that foods from these sources, if not properly handled, could serve as vehicles for its transmission to humans.

A prolonged outbreak of Salmonella Typhimurium infection related to an uncommon vehicle: hard cheese made from raw milk

In 2006, in The Netherlands, an outbreak of Salmonella Typhimurium phage type 561 (STM DT7, corresponding to the rare DT7 in the international typing scheme) was detected, accumulating to over 200 cases. By telephone interviews, data were collected from all laboratory-confirmed cases. In addition, in August 2006, a case-control study was performed in a subset of cases. Environmental and microbiological investigation was performed on a suspected dairy farm. In the case-control study (51 cases, 105 matched controls), hard cheese purchased from a farm, specifically farm X, and from a market stall were found to be associated with infection. The dairy production room of farm X tested STM DT7-positive in August. However, it was only in November, after earlier unsuccessful attempts, that a low-level contamination was confirmed in the hard farmhouse cheese, triggering control measures. A timely and adequate response was hampered during this outbreak for several reasons. Measures for improvement in handling future similar incidents are discussed.

Variation in Antimicrobial resistance in sporadic and outbreak-related Salmonella enterica serovar Typhimurium

The prevalence of different antimicrobial resistance profiles and variants of the Salmonella genomic island 1 (SGI1) was reported for Salmonellaenterica serovar Typhimurium DT104 strains isolated from patients in Denmark. Variation in antimicrobial resistance and corresponding changes of SGI1 were shown among isolates from a foodborne outbreak.

A comparison of two PCR-based typing methods with pulsed-field gel electrophoresis in Salmonella enterica serovar Enteritidis

Two novel molecular typing methods, multiple-locus variable-number tandem repeats (VNTR) analysis (MLVA) and multiple amplification of phage loci typing (MAPLT), were compared with pulsed-field gel electrophoresis (PFGE) for the discrimination of 128 Salmonella enterica serovar Enteritidis (S. Enteritidis) isolates. Selected epidemiologically unrelated isolates represented a cross-section of phage types routinely isolated in Australia and included 28 isolates that could not be assigned a phage type. Targeting 5 previously described loci, MLVA generated 61 different profiles with a Simpson index of diversity of DI=0.968. MLVA locus STTR-5 proved to be the most diverse with 11 different alleles detected with a Nei's diversity index value of D=0.769. Using 8 MAPLT primers previously developed for S. Typhimurium produced 36 different profiles with a DI value of 0.948. By contrast, PFGE only generated 13 different pulsed-field patterns, DI=0.873. Within each phage type there was variation in the extent to which either molecular method was able to discriminate the S. Enteritidis isolates. MAPLT provided more discrimination in terms of the number of profiles and DI value for phage type 1 and the untypable strains while MLVA was more discriminatory for phage types 14var and 26. There was a general lack of concordance of either molecular assay to phage type. These results suggest that both MAPLT and MLVA have excellent potential as tools for epidemiological studies of S. Enteritidis.

Towards bioinformatics assisted infectious disease control

BACKGROUND

This paper proposes a novel framework for bioinformatics assisted biosurveillance and early warning to address the inefficiencies in traditional surveillance as well as the need for more timely and comprehensive infection monitoring and control. It leverages on breakthroughs in rapid, high-throughput molecular profiling of microorganisms and text mining.

RESULTS

This framework combines the genetic and geographic data of a pathogen to reconstruct its history and to identify the migration routes through which the strains spread regionally and internationally. A pilot study of Salmonella typhimurium genotype clustering and temporospatial outbreak analysis demonstrated better discrimination power than traditional phage typing. Half of the outbreaks were detected in the first half of their duration.

CONCLUSION

The microbial profiling and biosurveillance focused text mining tools can enable integrated infectious disease outbreak detection and response environments based upon bioinformatics knowledge models and measured by outcomes including the accuracy and timeliness of outbreak detection.

A comparison of three molecular typing methods for the discrimination of Salmonella enterica serovar Infantis

Seventy-six epidemiologically unrelated Salmonella enterica serovar Infantis (S. Infantis) isolates were typed by pulsed-field gel electrophoresis (PFGE), multiple amplification of phage loci typing (MAPLT) and multiple-locus variable-number tandem-repeat analysis (MLVA). PFGE, using the restriction endonuclease XbaI, generated 23 different profiles for the 76 isolates (DI=0.848). MAPLT was undertaken using a combination of 11 primer sets based on bacteriophage sequences and generated 28 different profiles (DI=0.938). By contrast, MLVA only produced nine profiles (DI=0.668) with 13 different primer sets, including the five primer sets routinely used for S. Typhimurium typing. Reducing the number of MAPLT primer sets to four still provided a diversity index of 0.838. All three typing methods revealed two distinct lineages of S. Infantis, with most isolates demonstrating genetic traits of either lineage but not both. The results demonstrate that MAPLT can potentially provide greater discrimination and separation of S. Infantis isolates than both PFGE and MLVA. Furthermore, MAPLT data can be generated much more rapidly and with reduced labour input than PFGE and without the need for expensive PFGE electrophoresis equipment, nor does it require capillary sequencing of PCR fragments to accurately determine PCR fragment lengths as is the case with MLVA.

Salmonella serovar identification using PCR-based detection of gene presence and absence

There are more than 2,500 known Salmonella serovars, and some of these can be further subclassified into groups of strains that differ profoundly in their gene content. We refer to these groups of strains as "genovars." A compilation of comparative genomic hybridization data on 291 Salmonella isolates, including 250 S. enterica subspecies I strains from 32 serovars (52 genovars), was used to select a panel of 384 genes whose presence and absence among serovars and genovars was of potential taxonomic value. A subset of 146 genes was used for real-time PCR to successfully identify 12 serovars (16 genovars) in 24 S. enterica strains. A further subset of 64 genes was used to identify 8 serovars (9 genovars) in 12 multiplex PCR mixes on 11 S. enterica strains. These gene panels distinguish all tested S. enterica subspecies I serovars and their known genovars, almost all by two or more informative markers. Thus, a typing methodology based on these predictive genes would generally alert users if there is an error, an unexpected polymorphism, or a potential new genovar.

Multi-locus variable-number tandem repeat analysis for outbreak studies of Salmonella enterica serotype Enteritidis

Background

Salmonella enterica subsp. enterica serotype Enteritidis is known as an important and pathogenic clonal group which continues to cause worldwide sporadic cases and outbreaks in humans. Here a new multiple-locus variable-number tandem repeat analysis (MLVA) method is reported for highly-discriminative subtyping of Salmonella Enteritidis. Emphasis was given on the most predominant phage types PT4 and PT8. The method comprises multiplex PCR specifically amplifying repeated sequences from nine different loci followed by an automatic fragment size analysis using a multicolor capillary electrophoresis instrument. A total of 240 human, animal, food and environmental isolates of S. Enteritidis including 23 definite phage types were used for development and validation. Furthermore, the MLVA types were compared to the phage types of several isolates from two recent outbreaks to determine the concordance between both methods and to estimate their in vivo stability. The in vitro stability of the two MLVA types specifically for PT4 and PT8 strains were determined by multiple freeze-thaw cycles.

Results

Seventy-nine different MLVA types were identified in 240 S. Enteritidis strains. The Simpson's diversity index for the MLVA method was 0.919 and Nei diversity values for the nine VNTR loci ranged from 0.07 to 0.65. Twenty-four MLVA types could be assigned to 62 PT4 strains and 21 types to 81 PT8 strains. All outbreak isolates had an indistinguishable outbreak specific MLVA type. The in vitro stability experiments showed no changes of the MLVA type compared to the original isolate.

Conclusion

This MLVA method is useful to discriminate S. Enteritidis strains even within a single phage type. It is easy in use, fast, and cheap compared to other high-resolution molecular methods and therefore an important tool for surveillance and outbreak studies for S. Enteritidis.

Using MLVA to type strains of Salmonella Typhimurium in New South Wales

Phage typing has been the traditional strain typing (or .fingerprinting.) method used in Australia for surveillance of common salmonella serovars (such as Salmonella Typhimurium) and outbreak investigations. The need for more accessible, discriminatory and objective methods has been recognised but, until now, none has been widely accepted. Recently, the molecular typing method, known as MLVA (multilocus variable number tandem repeat analysis), has been applied to several Salmonella serovars and promises to provide faster strain typing and cluster identification than phage typing, with comparable or better sensitivity. The present article is intended as a short primer on MLVA typing, which has recently been introduced into routine use at the New South Wales Enteric Reference Laboratory at the Centre for Infectious Diseases and Microbiology, Institute of Clinical Pathology and Medical Research, Westmead.

Stability of multiple-locus variable-number tandem repeats in Salmonella enterica serovar typhimurium

Variable-number tandem repeats (VNTRs) may evolve so rapidly that multiple profiles emerge during an outbreak. A total of 190 isolates from eight Salmonella enterica serovar Typhimurium outbreaks and 15 isolates from seven patients were analyzed by pulsed-field gel electrophoresis and VNTR typing. Small changes in loci were noted; otherwise, the VNTR profiles were stable during the course of the outbreaks.

Outbreak with multi-resistant Salmonella Typhimurium DT104 linked to carpaccio, Denmark, 2005

We report an outbreak with Salmonella Typhimurium DT104 resistant to six different antibiotic classes. The outbreak occurred in Denmark in July/August 2005 and was traced to a single restaurant. In addition to patient interviews, an important tool in the investigation of this outbreak was comparison by multi-locus variable number of tandem repeat analysis (MLVA) typing of patient strains with strains from the food surveillance system. This showed that the source of the outbreak was imported beef served as carpaccio. Carpaccio, thinly sliced raw fillet of beef, has not previously been associated with outbreaks, but should be considered a high-risk food item. This outbreak was one of two in different European Union (EU) countries traced back to beef from one company in a third EU country. This underscores the importance of efficient international Salmonella surveillance and food-safety control systems enabling timely interventions within the EU.