Mycobacteria in drinking water distribution systems: ecology and significance for human health

Nontuberculous mycobacterial infections among patients suspected of pulmonary tuberculosis

The purpose of this study was to present a retrospective analysis of the frequency of nontuberculous mycobacteria (NTM)-related pulmonary infections among the AFB-positive and/or culture-positive patients in the Warsaw region who were suspected of tuberculosis (TB) and hospitalized in the university hospital between 1999 and 2005. All the AFB-positive pulmonary samples were examined with a molecular method using the Amplicor MTB test (Roche) for detection of Mycobacterium tuberculosis complex, and all mycobacterial isolates were speciated by high performance liquid chromatography (HPLC) analysis of mycolic acids. Patients who met clinical, radiological, and bacteriological criteria of mycobacteriosis were classified according to the American Thoracic Society (ATS) guidelines for diagnosis of NTM related disease. Among the 445 smear-positive or/and culture-positive patients, 142 subjects (31.9%) were found to be infected with M. tuberculosis. Among 303 non-TB patients, mycobacteriosis was found in 27 (8.9%) subjects. The frequency of NTM-related lung disease as compared to the bacteriologically-confirmed lung TB was estimated at 1:5. The rapid, precise methods of NTM speciation are necessary for progress in diagnostics of NTM related diseases.

Incidence of nontuberculous mycobacteria in four hot water systems using various types of disinfection

The objective of this study was to determine the incidence of nontuberculous mycobacteria (NTM) in hot water systems of 4 selected hospital settings. The hospitals provided the following types of disinfection for their hot water systems: hydrogen peroxide and silver, thermal disinfection, chlorine dioxide, and no treatment (control). In each building, 6 samples were collected from 5 sites during a 3 month period. NTM were detected in 56 (46.7%) of 120 samples; the CFU counts ranged from 10 to 1625 CFU/L. The detected NTM species were the pathogens Mycobacterium kansasii, Mycobacterium xenopi, and Mycobacterium fortuitum and the saprophyte Mycobacterium gordonae. The most common to be isolated was M. xenopi, which was present in 51 samples. The hot water systems differed significantly in the incidence of NTM. NTM were not detected in the system treated by thermal disinfection, and a relatively low incidence (20% positive samples) was found in the system disinfected with chlorine dioxide. However, a high incidence was found in the control system with no additional disinfection (70% positives) and in the system using hydrogen peroxide and silver (97% positives). Water temperatures above 50 degrees C significantly limited the occurrence of NTM.

Targeting the rpoB gene using nested PCR-restriction fragment length polymorphism for identification of nontuberculous mycobacteria in hospital tap water

Nontuberculous mycobacteria (NTM) are ubiquitous in the environment and can cause nosocomial infections in immunocompromised patients. Recently the presence of NTM in public drinking water and hospital water distribution systems has been reported. Their ability to form biofilms and their resistance to chlorine both contribute to their survival and colonization in water distribution systems. Here we analyzed thirty-two hospital tap water samples that were collected from different locations in three hospitals so as to evaluate the prevalence of NTM species. The water samples were concentrated by membrane filtration and then eluted with sterilized water following sonication. Two-step direct PCR targeting the rpoB gene, restriction fragment length polymorphism (RFLP) using the MspI restriction enzyme, and sequence analysis were performed for identification of NTM to the species level. The sequences of each PCR product were analyzed using BLASTN. Seven samples (7/32, 21.9%) were positive for NTM as determined by nested-PCR. The PCR-RFLP results indicated five different patterns among the seven positive PCR samples. The water-born NTM were identified, including M. peregrinum, M. chelonae (2 cases), M. abscessus, M. gordonae (2 cases), and Mycobacterium sp. JLS. The direct two-step PCR-RFLP method targeting the rpoB gene was effective for the detection and the differentiation of NTM species from hospital tap water.

Biofilm development by potentially pathogenic non-pigmented rapidly growing mycobacteria

BACKGROUND

A study to evaluate the biofilm-development ability in three different media (Middlebrook 7H9, sterile tap water and PBS-5% glucose) was performed with 19 collection strains from 15 different species on non-pigmented rapidly growing mycobacteria (NPRGM). A microtiter plate assay was developed to evaluate the percentage of covered surface of the microtiter plate wells in different days from day 1 to day 69.

RESULTS

All strains were able to develop biofilm in all the tested media. Middlebrook 7H9 showed the fastest growth, followed by sterile tap water and PBS-5% glucose. A sigmoid growth curve was detected in all the strains both in Middlebrook 7H9 and in sterile tap water. A difference could be detected for Mycobacterium abscessus in tap water, where it showed faster growth than all the other strains.

CONCLUSION

Biofilm development seems to be a property of all the species of NPRGM and it depends on the nutrients present in the medium. The microtiter plate assay described here is a useful tool to evaluate differences in biofilm development among the different species of rapidly growing mycobacteria.

Comparison of methods for processing drinking water samples for the isolation of Mycobacterium avium and Mycobacterium intracellulare

Several protocols for isolation of mycobacteria from water exist, but there is no established standard method. This study compared methods of processing potable water samples for the isolation of Mycobacterium avium and Mycobacterium intracellulare using spiked sterilized water and tap water decontaminated using 0.005% cetylpyridinium chloride (CPC). Samples were concentrated by centrifugation or filtration and inoculated onto Middlebrook 7H10 and 7H11 plates and Lowenstein-Jensen slants and into mycobacterial growth indicator tubes with or without polymyxin, azlocillin, nalidixic acid, trimethoprim, and amphotericin B. The solid media were incubated at 32 degrees C, at 35 degrees C, and at 35 degrees C with CO(2) and read weekly. The results suggest that filtration of water for the isolation of mycobacteria is a more sensitive method for concentration than centrifugation. The addition of sodium thiosulfate may not be necessary and may reduce the yield. Middlebrook M7H10 and 7H11 were equally sensitive culture media. CPC decontamination, while effective for reducing growth of contaminants, also significantly reduces mycobacterial numbers. There was no difference at 3 weeks between the different incubation temperatures.

Investigation of characteristics and factors associated with avian mycobacteriosis in zoo birds

The objective of the current study was to identify factors associated with avian mycobacteriosis in zoo birds. Inventory data, population health records, and necropsy data from eligible birds in the Zoological Society of San Diego's (ZSSD) collection from 1991–2005 ( n = 13,976) were used to describe disease incidence, prevalence, and postmortem findings. A matched case-control study was then conducted to identify factors describing demographic, temporal, and enclosure characteristics, along with move and exposure histories. Cases (disease-positive birds; n = 167) were matched in a 1:7 ratio with controls (disease-negative birds; n = 1169) of similar age and taxonomic grouping. Potential risk factors were evaluated using univariate and multivariable conditional logistic regression. Disease prevalence and incidence were estimated for the study period at 1.2% and 3 cases/(1,000 bird-years at risk), respectively. Lesion characteristics and order prevalence are described. In the multivariable model, case birds were more likely to have been previously housed with a bird with mycobacterial disease involving the intestinal tract (odds ratio [OR] = 5.6, P < 0.01) or involving only nonintestinal sites (OR = 2.0, P < 0.01). Cases were more likely to have been imported into the collection than hatched at the ZSSD (OR = 4.2, P < 0.01). Cases were moved among ZSSD enclosures more than controls (OR = 1.1 for each additional move, P < 0.01). Findings will help guide future management of this disease for zoo bird populations.

Mycobacterium avium subsp. paratuberculosis and M. avium subsp. avium are independently evolved pathogenic clones of a much broader group of M. avium organisms

Mycobacterium avium comprises organisms that share the same species designation despite considerable genomic and phenotypic variability. To determine the degree and nature of variability between subspecies and strains of M. avium, we used multilocus sequencing analysis, studying 56 genetically diverse strains of M. avium that included all described subspecies. In total, 8,064 bp of sequence from 10 gene loci were studied, with 205 (2.5%) representing variable positions. The majority (149/205) of these variations were found among M. avium subsp. hominissuis organisms. Recombination was also evident in this subspecies. In contrast, there was comparatively little variability and no evidence of recombination within the pathogenic subspecies, M. avium subsp. paratuberculosis, M. avium subsp. avium, and M. avium subsp. silvaticum. Phylogenetic analysis showed that M. avium subsp. avium and M. avium subsp. silvaticum strains clustered together on one branch, while a distinct branch defined M. avium subsp. paratuberculosis organisms. Despite the independent origin of these pathogenic subspecies, an analysis of their rates of nonsynonymous (dN) to synonymous (dS) substitutions showed increased dN/dS ratios for both: 0.67 for M. avium subsp. paratuberculosis and 0.50 for M. avium subsp. avium/M. avium subsp. silvaticum, while the value was 0.08 for M. avium subsp. hominissuis organisms. In conclusion, M. avium subsp. hominissuis represents a diverse group of organisms from which two pathogenic clones (M. avium subsp. paratuberculosis and M. avium subsp. avium/M. avium subsp. silvaticum) have evolved independently.

Tuberculosis and nontuberculous mycobacterial infections in older adults

Tuberculosis is one of the world's great public health crises. It is estimated by the World Health Organization that roughly one third of the world's populations, or some 2 billion people, are infected with Mycobacterium tuberculosis, the causative agent. More than 8 million people every year develop active tuberculosis disease, and 2 million die as a result. This article reviews tuberculosis and nontuberculous mycobacterial infections in older adults.

Risk of waterborne illness via drinking water in the United States

Outbreaks of disease attributable to drinking water are not common in the U.S., but they do still occur and can lead to serious acute, chronic, or sometimes fatal health consequences, particularly in sensitive and immunocompromised populations. From 1971 to 2002, there were 764 documented waterborne outbreaks associated with drinking water, resulting in 575,457 cases of illness and 79 deaths (Blackburn et al. 2004; Calderon 2004); however, the true impact of disease is estimated to be much higher. If properly applied, current protocols in municipal water treatment are effective at eliminating pathogens from water. However, inadequate, interrupted, or intermittent treatment has repeatedly been associated with waterborne disease outbreaks. Contamination is not evenly distributed but rather affected by the number of pathogens in the source water, the age of the distribution system, the quality of the delivered water, and climatic events that can tax treatment plant operations. Private water supplies are not regulated by the USEPA and are generally not treated or monitored, although very few of the municipal systems involved in documented outbreaks exceeded the USEPA's total coliform standard in the preceding 12 mon (Craun et al. 2002). We provide here estimates of waterborne infection and illness risks in the U.S. based on the total number of water systems, source water type, and total populations exposed. Furthermore, we evaluated all possible illnesses associated with the microbial infection and not just gastroenteritis. Our results indicate that 10.7 M infections/yr and 5.4 M illnesses/yr occur in populations served by community groundwater systems; 2.2 M infections/yr and 1.1 M illnesses/yr occur in noncommunity groundwater systems; and 26.0 M infections/yr and 13.0 M illnesses/yr occur in municipal surface water systems. The total estimated number of waterborne illnesses/yr in the U.S. is therefore estimated to be 19.5 M/yr. Others have recently estimated waterborne illness rates of 12M cases/yr (Colford et al. 2006) and 16 M cases/yr (Messner et al. 2006), yet our estimate considers all health outcomes associated with exposure to pathogens in drinking water rather than only gastrointestinal illness. Drinking water outbreaks exemplify known breaches in municipal water treatment and distribution processes and the failure of regulatory requirements to ensure water that is free of human pathogens. Water purification technologies applied at the point-of-use (POU) can be effective for limiting the effects of source water contamination, treatment plant inadequacies, minor intrusions in the distribution system, or deliberate posttreatment acts (i.e., bioterrorism). Epidemiological studies are conflicting on the benefits of POU water treatment. One prospective intervention study found that consumers of reverse-osmosis (POU) filtered water had 20%-35% less gastrointestinal illnesses than those consuming regular tap water, with an excess of 14% of illness due to contaminants introduced in the distribution system (Payment 1991, 1997). Two other studies using randomized, blinded, controlled trials determined that the risks were equal among groups supplied with POU-treated water compared to untreated tap water (Hellard et al. 2001; Colford et al. 2003). For immunocompromised populations, POU water treatment devices are recommended by the CDC and USEPA as one treatment option for reducing risks of Cryptosporidium and other types of infectious agents transmitted by drinking water. Other populations, including those experiencing "normal" life stages such as pregnancy, or those very young or very old, might also benefit from the utilization of additional water treatment options beyond the current multibarrier approach of municipal water treatment.

Synthesis, Characterization and Antimycobacterial Activity of Ag(I)-Aspartame, Ag(I)-Saccharin and Ag(I)-Cyclamate Complexes

The present work describes the synthesis and antimycobacterial activity of three Ag(I)-complexes with the sweeteners aspartame, saccharin, and cyclamate as ligands, with the aim of finding new candidate substances for fighting tuberculosis and other mycobacterial infections. The minimal inhibitory concentration of these three complexes was investigated in order to determine their in-vitro antimycobacterial activity against Mycobacterium tuberculosis, Mycobacterium avium, Mycobacterium intracellulare, Mycobacterium malmoense, and Mycobacterium kansasii. The MIC values were determined using the Microplate Alamar Blue Assay. The best MIC values found for the complexes were 9.75 microM for Ag(I)-aspartame against M. kansasii and 15.7 microM for Ag(I)-cyclamate against M. tuberculosis.

Survival of Mycobacterium avium in drinking water biofilms as affected by water flow velocity, availability of phosphorus, and temperature

Mycobacterium avium is a potential pathogen occurring in drinking water systems. It is a slowly growing bacterium producing a thick cell wall containing mycolic acids, and it is known to resist chlorine better than many other microbes. Several studies have shown that pathogenic bacteria survive better in biofilms than in water. By using Propella biofilm reactors, we studied how factors generally influencing the growth of biofilms (flow rate, phosphorus concentration, and temperature) influence the survival of M. avium in drinking water biofilms. The growth of biofilms was followed by culture and DAPI (4',6'-diamidino-2-phenylindole) staining, and concentrations of M. avium were determined by culture and fluorescence in situ hybridization methods. The spiked M. avium survived in biofilms for the 4-week study period without a dramatic decline in concentration. The addition of phosphorus (10 microg/liter) increased the number of heterotrophic bacteria in biofilms but decreased the culturability of M. avium. The reason for this result is probably that phosphorus increased competition with other microbes. An increase in flow velocity had no effect on the survival of M. avium, although it increased the growth of biofilms. A higher temperature (20 degrees C versus 7 degrees C) increased both the number of heterotrophic bacteria and the survival of M. avium in biofilms. In conclusion, the results show that in terms of affecting the survival of slowly growing M. avium in biofilms, temperature is a more important factor than the availability of nutrients like phosphorus.

In-vitro evaluation of the adhesion to polypropylene sutures of non-pigmented, rapidly growing mycobacteria

The ability of non-pigmented, rapidly growing mycobacteria (NPRGM) to attach to polypropylene sutures was evaluated using an in-vitro assay. Thirty clinical isolates and five culture collection strains of NPRGM, together with Staphylococcus epidermidis ATCC 35983, were tested. Mycobacterium fortuitum and Mycobacterium chelonae showed the highest attachment ability, which differed significantly from the results obtained with Mycobacterium peregrinum. According to these results, NPRGM are able to attach to polypropylene sutures, and the species implicated most frequently in human infection showed increased levels of attachment in comparison with the other mycobacteria studied.

Mycobacteria as environmental portent in Chesapeake Bay fish species

Infection with environmental mycobacteria is increasing among many Chesapeake Bay fish species. Prevalence in juvenile Atlantic menhaden differed between tributaries and ranged from 2% to 57%. Mycobacterial infection may be a syndromic sentinel of altered environmental conditions that threaten aquatic animal health.

Diversity of environmental Mycobacterium isolates from hemodialysis water as shown by a multigene sequencing approach

Here we used a multigene sequencing approach for the identification and molecular typing of environmental mycobacteria of the fast-growing subgroup. Strains were isolated from hemodialysis water and clinical samples. Eleven type strains of related species of the genus were also included in this study. To gain further insight into the diversity of the environmental mycobacteria, we analyzed several housekeeping genes (16S rRNA, ITS1, gyrB, hsp65, recA, rpoB, and sodA). No individual phylogenetic tree allowed good discrimination of all of the species studied. However, a concatenated and a consensus analysis, combining the genes, allowed better discrimination of each strain to the species level, and the increase in sequence size also led to greater tree robustness. This approach is useful not only for the discrimination and identification of environmental mycobacteria but also for their molecular typing and studies of population genetics. Our results demonstrate high genetic diversity among the isolates obtained, which are probably new species of the genus.

Synthesis, X-ray structure and antimycobacterial activity of silver complexes with α-hydroxycarboxylic acids

In this paper, synthesis, characterization and antimycobacterial properties of a new water-soluble complex identified as silver-mandelate are described. Elemental and thermal analyses are consistent with the formula [Ag(C(6)H(5)C(OH)COO)](n). The polymeric structure was determined by single X-ray diffraction and the two-dimensional structure is based on the bis(carboxylate-O,O') dimer [Ag-O, 2.237(3), 2.222(3) Angstrom]. The structure is extended along both the b and c axes through two oxygen atoms of a bidentate alpha-hydroxyl-carboxylate residue [Ag-OH(hydroxyl), 2.477(3) Angstrom; Ag-O(carboxylate), 2.502(3) Angstrom; O-Ag-O, 63.94(9) degrees]. A strong d(10)-d(10) interaction was observed between two silver atoms. The Ag - Ag distance is 2.8307(15) Angstrom. The NMR (13)C spectrum in D(2)O shows that coordination of the ligand to Ag(I) occurs through the carboxylate group in solution. Potentiometric titration shows that only species with a molar metal:ligand ratio of 2:2 are formed in aqueous solution. The mandelate complex and the silver-glycolate, silver-malate and silver-hydrogen-tartarate complexes were tested against three types of mycobacteria, Mycobacterium avium, Mycobacterium tuberculosis and Mycobacterium kansasii, and their minimal inhibitory concentration (MIC) values were determined. The results show that the four complexes are potential candidates for antiseptic or disinfectant drugs for discharged secretions of patients affected with tuberculosis.

Processes controlling the transmission of bacterial pathogens in the environment

Many pathogens in the environment can be transmitted to human populations and cause outbreaks and epidemics. Transmission is a multifactorial process influenced by the physiology of the pathogen as it exits its initial host, the mechanisms it uses for surviving outside the host, the physiology of the pathogen as it enters the next susceptible host and its ability to establish a successful infection. Few studies so far have focused on the processes responsible for modulating microbial survival in non-host environments and the transmission dynamics between infected and susceptible hosts, as well as the interplay between hosts. A better understanding of these mechanisms is thus necessary for predicting and preventing future outbreaks.

Interactions between Mycobacterium xenopi, amoeba and human cells

Outbreaks due to Mycobacterium xenopi have been linked with contaminated water. M. xenopi has been shown to interact with the biofilm formed in water distribution systems and to be hosted by free-living Acanthamoeba. The present study investigated the interaction between M. xenopi and A. polyphaga amoeba, and between M. xenopi and human fibroblast HEL cells. Examination using the light microscopy together with electronic and confocal microscopy demonstrated that M. xenopi was located within the amoeba and in HEL cells. The Light Cycler measurement of the M. xenopi:A. polyphaga DNA ratio and the M. xenopi:HEL cell DNA ratio demonstrated intra-amoebal and intracellular growth of M. xenopi with doubling-times of five-days and 10 days, respectively. Intra-amoebal M. xenopi survived protozoan encystment and germination. These data demonstrate that M. xenopi is a facultative intra-amoebal and intracellular pathogen. Testing intra-amoebal M. xenopi might be necessary to properly evaluate decontamination procedures for hospital water supply systems in order to achieve eradication.

Roles for cell wall glycopeptidolipid in surface adherence and planktonic dispersal of Mycobacterium avium

The opportunistic pathogen Mycobacterium avium is a significant inhabitant of biofilms in drinking water distribution systems. M. avium expresses on its cell surface serovar-specific glycopeptidolipids (ssGPLs). Studies have implicated the core GPL in biofilm formation by M. avium and by other Mycobacterium species. In order to test this hypothesis in a directed fashion, three model systems were used to examine biofilm formation by mutants of M. avium with transposon insertions into pstAB (also known as nrp and mps). pstAB encodes the nonribosomal peptide synthetase that catalyzes the synthesis of the core GPL. The mutants did not adhere to polyvinyl chloride plates; however, they adhered well to plastic and glass chamber slide surfaces, albeit with different morphologies from the parent strain. In a model that quantified surface adherence under recirculating water, wild-type and pstAB mutant cells accumulated on stainless steel surfaces in equal numbers. Unexpectedly, pstAB mutant cells were >10-fold less abundant in the recirculating-water phase than parent strain cells. These observations show that GPLs are directly or indirectly required for colonization of some, but by no means all, surfaces. Under some conditions, GPLs may play an entirely different role by facilitating the survival or dispersal of nonadherent M. avium cells in circulating water. Such a function could contribute to waterborne M. avium infection.

Survival of environmental mycobacteria in Acanthamoeba polyphaga

Free-living amoebae in water are hosts to many bacterial species living in such an environment. Such an association enables bacteria to select virulence factors and survive in adverse conditions. Waterborne mycobacteria (WBM) are important sources of community- and hospital-acquired outbreaks of nontuberculosis mycobacterial infections. However, the interactions between WBM and free-living amoebae in water have been demonstrated for only few Mycobacterium spp. We investigated the ability of a number (n = 26) of Mycobacterium spp. to survive in the trophozoites and cysts of Acanthamoeba polyphaga. All the species tested entered the trophozoites of A. polyphaga and survived at this location over a period of 5 days. Moreover, all Mycobacterium spp. survived inside cysts for a period of 15 days. Intracellular Mycobacterium spp. within amoeba cysts survived when exposed to free chlorine (15 mg/liter) for 24 h. These data document the interactions between free-living amoebae and the majority of waterborne Mycobacterium spp. Further studies are required to examine the effects of various germicidal agents on the survival of WBM in an aquatic environment.