Antimicrobial resistance among enteric pathogens

Presence of Resistant DEC Strains in a Tertiary Healthcare Center in North East India in Children under 18 Years

Introduction  Diarrheal illness such as diarrheagenic Escherichia coli (DEC), apart from rotavirus, is a common etiological agent known to cause moderate-to-severe diarrhea in low-income countries where unregulated use of antibiotics is rampant, giving rise to multidrug resistant (MDR) strains. This study is an earnest effort in reflecting the resistance pattern in such isolates.

Materials and Methods  It is a hospital-based cross-sectional study conducted over a period of 1 year (January to December, 2015). Children aged less than 18 years presenting with ( n  = 170) and without ( n  = 47) diarrhea were included as cases and controls, respectively. Fresh stool sample from eligible participants was collected and inoculated on MacConkey agar. Based on the colony morphology and biochemical identification followed by polymerase chain reaction (PCR), different pathotypes of DEC were identified. All such isolates were subjected to antimicrobial susceptibility testing employing VITEK 2 identification system. The result of the tested antibiotics was evaluated as per Clinical and Laboratory Standards Institute 2015 guidelines.

Results  DEC with specific virulence genes were detected by multiplex real-time PCR in 39 and 3 children with or without diarrhea, respectively. Most common DEC pathotypes found were enteroaggregative E. coli (38%) followed by enteropathogenic E. coli (28.5%). MDR isolates comprised 35 of 42 DEC pathotypes (83.3%). Resistance among DEC pathotypes to ampicillin, amoxicillin–clavulanate, ciprofloxacin, cephalosporin, nalidixic acid, imipenem, and cotrimoxazole was found to be statistically significant in comparison to non-DEC isolates.

Conclusion  This study has highlighted the increased prevalence of MDR strains among DEC pathotypes. Looking for these isolates will help detect dreadful DEC pathotypes like enterohemorrhagic E. coli where early administration of a sensitive antibiotic will go a long way in preventing complication like hemorrhagic colitis and hemolytic uremic syndrome.

The Ecology and Antibiotic Resistance Patterns of Gastrointestinal Tract Infections in A Tertiary Care Hospital in Oman

A wide range of gastrointestinal (GI) illnesses is caused by foodborne bacteria that can arise from either a direct bacterial infection or bacterial toxin ingestion. The treatment of these infections has been hampered by the appearance of resistant strains. This current study aims to investigate the prevalence of Gastrointestinal tract (GIT) infections in Omani patients and their resistance pattern against commonly used antibiotics. Seven hundred and ninety fresh stool samples were obtained from Omani patients attending Sultan Qaboos University Hospital with GI manifestation from the 1st of June to the 30th of November 2019. Bacterial identification in stool samples was carried out by inoculation in culture media, microscopical examination and biochemical tests confirmed by MALDI. BD PhoenixTM. The antibiotics sensitivity testing was carried out by the Manual disk diffusion method and by MALDI. BD PhoenixTM. Out of 790 stool samples, 49 samples were positive for GIT bacterial infections. Salmonella spp. was the most prevalent isolate and more associated with children less than ten years old. Out of the 49 bacterial isolates, 3 (6.1%) were Clostridium difficili, 4 (8.2%) were Shigella flexneri, 5 (10.2%) were Campylobacter jejuni, and different Salmonella spp. serotypes were detected such as Salmonella Kentucky (8.2%), Salmonella enteritidis (6.1%), Salmonella infantis (4.1%), Salmonella welteverden (4.1%), Salmonella typhimurium (4.1%), Salmonella anatum (2.0%), Salmonella tesvia (2.0%), Salmonella Uganda (2.0%), Salmonella Arizona (2.0%) and (40.8%) of other Salmonella spp. serotypes. Eighty percent of isolated Campylobacter jejuni were resistant to Ciprofloxacin and Tetracycline. Salmonella spp. and Shigella flexneri were highly resistant to Amikacin, Gentamicin, and Cefuroxime. The low level of bacterial infection detected among screened patients in the present study indicates the excellent hand washing hygiene practice in reducing GIT infections among patients in Oman. This good hand washing hygiene practice is of great help in the efforts of controlling the spread of other severe diseases like COVID-19. However, detecting the emerging of antibiotic-resistant of GIT bacterial pathogens among patients in Oman, such as Salmonella and Shigella to a commonly used antibiotic such as Gentamicin, is alarming.

Diagnostic syndromic multiplex approaches for gastrointestinal infections

Introduction: Gastrointestinal diseases due to infectious pathogens currently represent an important global health concern, especially in children and developing countries. Early and accurate detection of gastrointestinal pathogens is important to initiate the appropriate type of therapy. Multiplex molecular gastrointestinal panels rapidly detect several gastrointestinal pathogens at once with high sensitivity.Areas covered: We assess the scope and limitations of several multiplex gastrointestinal panels approved by the Food and Drug Administration or marked by Conformité Européenne-in vitro diagnostic. We compare 10 syndromic gastrointestinal panels, 14 bacteria-specific multiplex panels, seven parasite-specific multiplex panels, and eight virus-specific multiplex panels.Expert opinion: Thanks to the advances made in the diagnostic approaches for gastrointestinal infections, there are various panels to choose. The choice of a specific syndromic gastrointestinal multiplex panel should be made to improve patient care. Diagnostic syndromic multiplex approaches for gastrointestinal infections should be customized; each hospital should develop its diagnostic algorithm for gastrointestinal infections tailored to its setting, study population, and geographical site. Current multiplex gastrointestinal panels could be improved by including the detection of antimicrobial resistance, toxigenic Clostridioides difficile, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, the virus responsible for the COVID-19 pandemic).

Effects of treatment with enrofloxacin or tulathromycin on fecal microbiota composition and genetic function of dairy calves

The increasing concerns with antimicrobial resistance highlights the need for studies evaluating the impacts of antimicrobial use in livestock on antimicrobial resistance using new sequencing technologies. Through shotgun sequencing, we investigated the changes in the fecal microbiome composition and function, with a focus on functions related to antimicrobial resistance, of dairy calves. Heifers 2 to 3 weeks old, which were not treated with antibiotics by the farm before enrollment, were randomly allocated to one of three study groups: control (no treatment), a single treatment of enrofloxacin, or a single treatment of tulathromycin. Fecal samples were collected at days 4, 14, 56 and 112 days after enrollment, and DNA extraction and sequencing was conducted. The effect of antibiotic treatment on each taxon and genetic functional level by time (including Day 0 as a covariate) revealed few changes in the microbiota. At the genus level, enrofloxacin group had higher relative abundance of Blautia, Coprococcus and Desulfovibrio and lower abundance of Bacteroides when compared to other study groups. The SEED database was used for genetic functional analyses, which showed that calves in the enrofloxacin group started with a higher relative abundance of "Resistance to antibiotics and toxic compounds" function on Day 0, however an increase in antibiotic resistance genes after treatment with enrofloxacin was not observed. "Resistance to Fluoroquinolones" and "Erythromycin resistance", of relevance given the study groups, were not statistically different in relative abundance between study groups. "Resistance to fluoroquinolones" increased during the study period regardless of study group. Despite small differences over the first weeks between study groups, at Day 112 the microbiota composition and genetic functional profile was similar among all study groups. In our study, enrofloxacin or tulathromycin had minimal impacts on the microbial composition and genetic functional microbiota of calves over the study period.

Pediatric Genitourinary Infections and Other Considerations

Pediatric patients pose a unique host of challenges to the emergency provider across all complaints and ages, but this is particularly notable in the genitourinary (GU) system. The pediatric GU system is different from that of the adult in its etiology of symptoms, complications, and treatments. Based on age, there are variations in the anatomy. These differences result in symptoms and diagnoses that must be managed differently. Although in many respects management is similar to GU emergency conditions in adults, there are, occasionally subtle, differences between the care of children and adults, which can greatly impact outcomes.

Prevalence of enteric bacteria and their antimicrobial susceptibility patterns among food handlers in Gondar town, Northwest Ethiopia

Background

Enteric bacterial pathogens are the major causes of food-borne gastroenteritis in humans and remain important public health problems worldwide. The emergence of antimicrobial resistance is a global concern, particularly in developing countries. The aim of this study was to determine the prevalence of enteric bacteria pathogens and their antimicrobial susceptibility patterns among food handlers in Gondar town, Northwest Ethiopia.

Methods

A cross-sectional study was conducted from February 4 to April 16, 2018. A total of 257 food handlers were selected using a multistage sampling technique. Data on socio-demographic characteristics were collected using a structured questionnaire. Stool samples were collected and inoculated into appropriate media. Enteric bacterial pathogens were identified using standard microbiological methods. Antimicrobial susceptibility tests were performed using the disk diffusion technique as per the standard Kirby-Bauer method. Data were entered and analyzed using SPSS version 20 software.

Results

The overall prevalence of enteric bacteria was 34/257 (13. 2%, [95% CI, 8.9-17.5%]). Shigella species was the leading isolate that accounted for 26/257 (10.1%) followed by Enterohemorrhagic Escherichia coli (EHEC) O157: H7 5/257 (1.9%) and Salmonella species 3/257 (1.2%). Shigella spp. was susceptible to ciprofloxacin 26 (100%), ceftriaxone 25 (96.1%), chloramphenicol 24 (92.3%), nalidixic acid 24 (92.3%), and gentamicin 20 (76.9%). Escherichia coli O157: H7 and Salmonella spp. showed the maximum (100%) susceptibility results to ceftriaxone, chloramphenicol, ciprofloxacin, and gentamicin. The overall prevalence of Multidrug resistance (MDR) in the current study was 14/34 (41.2%).

Conclusion

Our study showed high prevalence of enteric bacterial pathogens among food handlers. All isolates were susceptible to ciprofloxacin. However, a substential number of isolates were resistant to commonly prescribed antibiotics and the prevalence of MDR was high.

Bacterial profile and antimicrobial susceptibility patterns in chronic suppurative otitis media at the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia

Objectives

This study aims to determine bacterial profile and antimicrobial susceptibility patterns of chronic suppurative otitis media in the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia.

Result

Sixty-two ear swabs were collected and 74 bacterial isolates were identified, of which 48 (77.4%) sample with mono-microbial growth, 11 (17.8%) with polymicrobial growth and the remaining 3 (4.8%) show no growth. The most common isolates were Proteus mirabilis 16 (21.6%), followed by S. aureus 12 (16.2%), Klebsiella spp. 10 (13.5%) and Providencia spp. 11 (14.9%). Proteus mirabilis was 100% susceptible to norfloxacin and ciprofloxacin while 87.5% of the isolates were susceptible to cefixime and gentamicin. S. aureus was 83.3% susceptible to gentamicin and clarithromycin, while 75% of the isolates were susceptible to amoxicillin–clavulanic acid and chloramphenicol, however, 66.7% the isolates were susceptible to ciprofloxacin, norfloxacin and erythromycin. The overall prevalence of multidrug resistance in the current study was 35 (47.3%). In this study P. mirabilis, S. aureus, Providencia spp., and Klebsiella spp. were the most common bacterial isolate and all Gram negative isolates were susceptible to ciprofloxacin and norfloxacin. Amoxicillin–clavulanic acid, gentamicin, chloramphenicol, clarithromycin and tobramycin were relatively effective against Gram positive bacteria.

Electronic supplementary material

The online version of this article (10.1186/s13104-019-4452-4) contains supplementary material, which is available to authorized users.

Antimicrobial resistance and genetic characterization of Shigella spp. in Shanxi Province, China, during 2006-2016

Background

Shigella spp., facultative anaerobic bacilli of the family Enterobacteriaceae, are one of the most common causes of diarrheal diseases in human worldwide which have become a significant public health burden. So, we aimed to analyze the antimicrobial phenotypes and to elucidate the molecular mechanisms underlying resistance to cephalosporins and fluoroquinolones in Shigella isolates from patients with diarrhea in Shanxi Province.

Results

During 2006–2016, we isolated a total of 474 Shigella strains (including 337 S. flexneri and 137 S. sonnei). The isolates showed high rates of resistance to traditional antimicrobials, and 26, 18.1 and 3.0% of them exhibited resistance to cephalosporins, fluoroquinolones and co-resistance to cephalosporins and fluoroquinolones, respectively. Notably, 91.1% of these isolates, including 22 isolates that showed an ACTSuT profile, exhibited multidrug resistance (MDR). The resistance rates to cephalosporins in S. sonnei isolates were higher than those in S. flexneri. Conversely, the resistance rates to fluoroquinolones were considerably higher in S. flexneri isolates. Among the 123 cephalosporins-resistant isolates, the most common extended-spectrum beta-lactamase gene was bla_TEM-1, followed by bla_CTX-M, bla_OXA-1, and bla_SHV-12. Six subtypes of bla_CTX-M were identified, bla_CTX-M-14 (n = 36) and bla_CTX-M-55 (n = 26) were found to be dominant. Of all the 86 isolates with resistance to fluoroquinolones and having at least one mutation (Ser83Leu, His211Tyr, or Asp87Gly) in the the quinolone resistance-determining regions of gyrA, 79 also had mutation of parC (Ser80Ile), whereas 7 contained plasmid-mediated quinolone resistance genes including qnrA, qnrB, qnrS, and aac(60)-Ib-cr. Furthermore, pulsed-field gel electrophoresis analysis (PFGE) showed a considerable genetic diversity in S. flexneri isolates. However, the S. sonnei isolates had a high genetic similarity.

Conclusions

Coexistence of diverse resistance genes causing the emergence and transmission of MDR might render the treatment of shigellosis difficult. Therefore, continuous surveillance might be needed to understand the actual disease burden and provide guidance for shigellosis.

Electronic supplementary material

The online version of this article (10.1186/s12866-019-1495-6) contains supplementary material, which is available to authorized users.

Enhanced Immunogenicity and Protective Efficacy of a Campylobacter jejuni Conjugate Vaccine Coadministered with Liposomes Containing Monophosphoryl Lipid A and QS-21

Campylobacter jejuni is among the most common causes of diarrheal disease worldwide and efforts to develop protective measures against the pathogen are ongoing. One of the few defined virulence factors targeted for vaccine development is the capsule polysaccharide (CPS). We have developed a capsule conjugate vaccine against C. jejuni strain 81-176 (CPS-CRM) that is immunogenic in mice and nonhuman primates (NHPs) but only moderately immunogenic in humans when delivered alone or with aluminum hydroxide. To enhance immunogenicity, two novel liposome-based adjuvant systems, the Army Liposome Formulation (ALF), containing synthetic monophosphoryl lipid A, and ALF plus QS-21 (ALFQ), were evaluated with CPS-CRM in this study. In mice, ALF and ALFQ induced similar amounts of CPS-specific IgG that was significantly higher than levels induced by CPS-CRM alone. Qualitative differences in antibody responses were observed where CPS-CRM alone induced Th2-biased IgG1, whereas ALF and ALFQ enhanced Th1-mediated anti-CPS IgG2b and IgG2c and generated functional bactericidal antibody titers. CPS-CRM + ALFQ was superior to vaccine alone or CPS-CRM + ALF in augmenting antigen-specific Th1, Th2, and Th17 cytokine responses and a significantly higher proportion of CD4+ IFN-γ+ IL-2+ TNF-α+ and CD4+ IL-4+ IL-10+ T cells. ALFQ also significantly enhanced anti-CPS responses in NHPs when delivered with CPS-CRM compared to alum- or ALF-adjuvanted groups and showed the highest protective efficacy against diarrhea following orogastric challenge with C. jejuni This study provides evidence that the ALF adjuvants may provide enhanced immunogenicity of this and other novel C. jejuni capsule conjugate vaccines in humans.IMPORTANCECampylobacter jejuni is a leading cause of diarrheal disease worldwide, and currently no preventative interventions are available. C. jejuni is an invasive mucosal pathogen that has a variety of polysaccharide structures on its surface, including a capsule. In phase 1 studies, a C. jejuni capsule conjugate vaccine was safe but poorly immunogenic when delivered alone or with aluminum hydroxide. Here, we report enhanced immunogenicity of the conjugate vaccine delivered with liposome adjuvants containing monophosphoryl lipid A without or with QS-21, known as ALF and ALFQ, respectively, in preclinical studies. Both liposome adjuvants significantly enhanced immunity in mice and nonhuman primates and improved protective efficacy of the vaccine compared to alum in a nonhuman primate C. jejuni diarrhea model, providing promising evidence that these potent adjuvant formulations may enhance immunogenicity in upcoming human studies with this C. jejuni conjugate and other malaria and HIV vaccine platforms.

A national framework for an antimicrobial resistance surveillance system within Iranian healthcare facilities: Towards a global surveillance system

OBJECTIVES

The threat of antimicrobial resistance (AMR) is growing rapidly, perhaps more dramatically in developing countries. A demand to monitor, surveil and predict AMR has prompted the design and implementation of AMR surveillance systems (AMRSSs) at all geographic levels, especially in the national context. This study reviewed AMRSSs in leading countries and organisations in order to customise a comprehensive framework for a national system in Iran.

METHODS

The research was conducted in two phases: a review of the literature and comparative analysis; and a knowledge, attitude and practice study. In the first phase, the AMRSSs of pioneering organisations and countries were reviewed by examining related documents. In the second phase, important components for the Iranian national system were determined on the basis of the World Health Organization's Global Antimicrobial Resistance Surveillance System (WHO GLASS).

RESULTS

This study determined the surveillance methods, priority specimens and pathogens, testing methods, reporting protocols and scheduling, recommended data sets, and tools and information flow necessary for the Iranian system. On this basis, a national framework was developed using the class and activity diagrams in Unified Modelling Language. A context diagram was also designed on the basis of a generic biosurveillance architecture.

CONCLUSIONS

The design and implementation of a national AMRSS for Iranian healthcare facilities is critically required because of irrational antimicrobial use in Iran and insufficient data regarding its consequences.

Resistant pathogens as causes of traveller's diarrhea globally and impact(s) on treatment failure and recommendations

BACKGROUND

: Diarrhea is a frequent clinical syndrome affecting international travellers. Bacterial etiologic agents have a long history of emergent antimicrobial resistance against commonly used antibiotics. Current approaches applying first-line antimicrobial therapy are being challenged by increasingly resistant organisms. This review summarizes recent epidemiological and clinical evidence of antibiotic resistance among enteropathogens causing traveller's diarrhea and the subsequent impact on current treatment recommendations.

METHODS

: The PubMed database was systemically searched for articles related to antibiotic susceptibility and diarrheal pathogens.

RESULTS

: Antibiotic resistance related to travellers' diarrhea has increased in recent years. Most notably, fluoroquinolone resistance has expanded from the Campylobacter -associated cases well documented in Southeast Asia in the 1990s to widespread occurrence, as well as increases among other common bacterial enteropathogens including, enterotoxigenic and enteroaggregative Escherichia coli , Shigella and non-typhoidal Salmonella . Multidrug resistance among enteropathogenic Enterobacteriacae and Campylobacter species create further challenges with the selection of empiric therapy. Treatment failures requiring early use of alternative agents, as well as delayed recovery comparable to placebo rates emphasize the impact of antimicrobial resistance on effective treatment.

CONCLUSIONS

: Although there are limitations in the available data, the increasing antibiotic resistance and adverse impact on clinical outcome require continued surveillance and reconsideration of practice guidelines.

Antimicrobial resistance profiles of Shiga toxin-producing Escherichia coli O157 and Non-O157 recovered from domestic farm animals in rural communities in Northwestern Mexico

Background

Antimicrobial resistance in Shiga toxin-producing Escherichia coli (STEC) O157 and non-O157 is a matter of increasing concern. The aim of the present study was to investigate the antimicrobial resistance profiles of STEC O157 and non-O157 recovered from feces of domestic farm animals in the agricultural Culiacan Valley in Northwestern Mexico.

Findings

All of the examined STEC strains showed susceptibility to five antimicrobials, ceftazidime, ceftriaxone, ciprofloxacin, nalidixic acid, and trimethoprim-sulfamethoxazole. However, resistance to the four antimicrobials, ampicillin, cephalothin, chloramphenicol, and kanamycin was commonly observed. Interestingly, non-susceptibility to cephalothin was predominant among the examined STEC strains, corresponding to 85 % (22/26) of the O157:H7 from cattle, sheep and chicken and 73 % (24/33) of the non-O157 strains from cattle and sheep. Statistical analyses revealed that resistance to ampicillin was significantly correlated to 38 % (10/26) of STEC O157:H7 strains from multiple animal sources. Another significant correlation was found between serotype, source, and antimicrobial resistance; all of the O20:H4 strains, recovered from sheep, were highly resistant to tetracycline. Multidrug resistance profiles were identified in 42 % (22/53) of the non-susceptible STEC strains with clinically-relevant serotypes O8:H9, O75:H8, O146:H21, and O157:H7.

Conclusions

STEC O157 and non-O157 strains, recovered from domestic farm animals in the Culiacan Valley, exhibited resistance to classes of antimicrobials commonly used in Mexico, such as aminoglycosides, tetracyclines, cephalosporins and penicillin but were susceptible to fluoroquinolones, quinolones, and sulfonamides. These findings provide fundamental information that would aid in the surveillance of antimicrobial resistance in an important agricultural region in Northwestern Mexico.

Electronic supplementary material

The online version of this article (doi:10.1186/s13756-015-0100-5) contains supplementary material, which is available to authorized users.

Effects of selection pressure and genetic association on the relationship between antibiotic resistance and virulence in Escherichia coli

Antibiotic selection pressure and genetic associations may lead to the cooccurrence of resistance and virulence in individual pathogens. However, there is a lack of rigorous epidemiological evidence that demonstrates the cooccurrence of resistance and virulence at the population level. Using samples from a population-based case-control study in 25 villages in rural Ecuador, we characterized resistance to 12 antibiotics among pathogenic (n = 86) and commensal (n = 761) Escherichia coli isolates, classified by the presence or absence of known diarrheagenic virulence factor genes. The prevalences of resistance to single and multiple antibiotics were significantly higher for pathogenic isolates than for commensal isolates. Using a generalized estimating equation, antibiotic resistance was independently associated with virulence factor carriage, case status, and antibiotic use (for these respective factors: odds ratio [OR] = 3.0, with a 95% confidence interval [CI] of 1.7 to 5.1; OR = 2.0, with a 95% CI of 1.3 to 3.0; and OR = 1.5, with a 95% CI of 0.9 to 2.5). Virulence factor carriage was more strongly related to antibiotic resistance than antibiotic use for all antibiotics examined, with the exception of fluoroquinolones, gentamicin, and cefotaxime. This study provides epidemiological evidence that antibiotic resistance and virulence factor carriage are linked in E. coli populations in a community setting. Further, these data suggest that while the cooccurrence of resistance and virulence in E. coli is partially due to antibiotic selection pressure, it is also genetically determined. These findings should be considered in developing strategies for treating infections and controlling for antibiotic resistance.

Comparative analysis of antimicrobial resistance in enterotoxigenic Escherichia coli isolates from two paediatric cohort studies in Lima, Peru

BACKGROUND

Antibiotic resistance is increasing worldwide, being of special concern in low- and middle-income countries. The aim of this study was to determine the antimicrobial susceptibility and mechanisms of resistance in 205 enterotoxigenic Escherichia coli (ETEC) isolates from two cohort studies in children <24 months in Lima, Peru.

METHODS

ETEC were identified by an in-house multiplex real-time PCR. Susceptibility to 13 antimicrobial agents was tested by disk diffusion; mechanisms of resistance were evaluated by PCR.

RESULTS

ETEC isolates were resistant to ampicillin (64%), cotrimoxazole (52%), tetracycline (37%); 39% of the isolates were multidrug-resistant. Heat-stable toxin producing (ETEC-st) (48%) and heat-labile toxin producing ETEC (ETEC-lt) (40%) had higher rates of multidrug resistance than isolates producing both toxins (ETEC-lt-st) (21%), p<0.05. Only 10% of isolates were resistant to nalidixic acid and none to ciprofloxacin or cefotaxime. Ampicillin and sulfamethoxazole resistance were most often associated with blaTEM (69%) and sul2 genes (68%), respectively. Tetracycline resistance was associated with tet(A) (49%) and tet(B) (39%) genes. Azithromycin inhibitory diameters were ≤15 mm in 36% of isolates, with 5% of those presenting the mph(A) gene.

CONCLUSIONS

ETEC from Peruvian children are often resistant to older, inexpensive antibiotics, while remaining susceptible to ciprofloxacin, cephalosporins and furazolidone. Fluoroquinolones and azithromycin remain the drugs of choice for ETEC infections in Peru. However, further development of resistance should be closely monitored.

Antimicrobial Resistance of Shigella flexneri Serotype 1b Isolates in China

Shigella flexneri serotype 1b is among the most prominent serotypes in developing countries, followed by serotype 2a. However, only limited data is available on the global phenotypic and genotypic characteristics of S. flexneri 1b. In the present study, 40 S. flexneri 1b isolates from different regions of China were confirmed by serotyping and biochemical characterization. Antimicrobial susceptibility testing showed that 85% of these isolates were multidrug-resistant strains and antibiotic susceptibility profiles varied between geographical locations. Strains from Yunnan were far more resistant than those from Xinjiang, while only one strain from Shanghai was resistant to ceftazidime and aztreonam. Fifteen cephalosporin resistant isolates were identified in this study. ESBL genes (bla_SHV, bla_TEM, bla_OXA, and bla_CTX-M) and ampC genes (bla_MOX,bla_FOX,bla_MIR(ACT-1),bla_DHA,bla_CIT and bla_ACC) were subsequently detected among the 15 isolates. The results showed that these strains were positive only for bla_TEM, bla_OXA, bla_CTX-M, intI1, and intI2. Furthermore, pulsed-field gel electrophoresis (PFGE) analysis showed that the 40 isolates formed different profiles, and the PFGE patterns of Xinjiang isolates were distinct from Yunnan and Shanghai isolates by one obvious, large, missing band. In summary, similarities in resistance patterns were observed in strains with the same PFGE pattern. Overall, the results supported the need for more prudent selection and use of antibiotics in China. We suggest that antibiotic susceptibility testing should be performed at the start of an outbreak, and antibiotic use should be restricted to severe Shigella cases, based on resistance pattern variations observed in different regions. The data obtained in the current study might help to develop a strategy for the treatment of infections caused by S. flexneri 1b in China.

Prevalence and antimicrobial resistance of Shigella flexneri serotype 2 variant in China

Shigella flexneri serotype 2 variant (II:3,4,7,8) was isolated in 2008 and first reported in China in 2013. In the present study, epidemiological surveillance from 2003 to 2013 in China suggested that this serotype first appeared in Guangxi in 2003; it then emerged in Shanghai and Xinjiang in 2004 and in Henan in 2008. Of the 1813 S. flexneri isolates, 58 S. flexneri serotype 2 variant strains were identified. Serotype 2 variant has emerged as a prominent serotype in recent years, with 2a (32.6%), X variant (25.2%), 1a (9.4%), X (6.3%), 2b (5.4%), and 1b (3.6%). According to phenotypic and genotypic analysis, the serotype 2 variant originated from 2a to 2b. A higher antibiotic resistance rate was observed between 2009 and 2013 than that between 2003 and 2008. Among 22 cephalosporin-resistant isolates, bla_TEM-1, bla_OXA-1, bla_CTX-3, bla_CTX-14, and bla_CTX-79 were detected. Among 22 fluoroquinolone-resistant isolates, a Ser80Ile mutation in parC was present in all of the isolates. Moreover, 21 isolates had three gyrA point mutations (Ser83Leu, His211Tyr, Asp87Asn, or Gly) and one isolate had two gyrA point mutations (Ser83Leu and His211Tyr). The prevalence of His211Tyr in the fluoroquinolone-resistant isolates is concerning, and the mutation was first reported in China. Besides, 22 isolates harbored the aac(6′)-Ib-cr gene, and two isolates harbored qnrS1. In view of the increased epidemic frequency and multidrug-resistant strain emergence, continuous surveillance will be needed to understand the actual disease burden and provide guidance for shigellosis.

Characterization of Diarrheagenic Antimicrobial Resistant Escherichia coli Isolated From Pediatric Patients in Tehran, Iran

Background:

Acute infectious diarrhea is one of the most important causes of morbidity and mortality worldwide.

Objectives:

The objective of this study was to characterize antimicrobial resistant diarrheagenic Escherichia coli strains isolated from diarrheic children in Tehran, IR Iran.

Patients and Methods:

In total, 550 stool samples from diarrheic pediatric patients, aged less than 60 months, were collected and immediately transferred to the laboratory. Isolation and identification of E. coli strains was done using bacteriological methods. Antimicrobial susceptibility testing was performed using the disk diffusion technique. Multiplex PCR was used to detect aadA1, tetA, tetB, dfrA1, qnr, aac (3)-IV, sul1, blaSHV, CITM, cat1, and cmlA antibiotic resistance genes.

Results:

From the total of 550 fecal samples examined, 154 samples (28%) were positive for diarraheagenic E. coli. High rates of antibiotic resistance were seen against penicillin ﴾100%), ampicillin ﴾89.6%﴿ and tetracycline ﴾83.1%﴿. Resistance against ciprofloxacin was low ﴾28.6%﴿. The prevalence of different resistance genes in the studied strains varied from 96.10% for aadA1 gene to 40.25% for sul1 gene. The frequencies of aadA1, tetA, tetB, dfrA1, qnr, aac(3)-IV, sul1, blaSHV, CITM, cat1, and cmlA genes were 96.10%, 85.06%, 84.41%, 51.94%, 72.07%, 54.54%, 40.25%, 57.79%, 90.25%, 59.74% and 60.38%, respectively.

Conclusions:

Our results indicated that antibiotic resistance is increasing in diarraheagenic E. coli strains in Iran. It is imperative to develop strategies for prevention and control of resistant organisms. Changes in patterns of resistance against commonly used antibiotics in Iran indicate that an applied surveillance system and introduction of guidelines for appropriate antibiotic prescription are necessary.

Small-molecule inhibitor of the Shigella flexneri master virulence regulator VirF

VirF is an AraC family transcriptional activator that is required for the expression of virulence genes associated with invasion and cell-to-cell spread by Shigella flexneri, including multiple components of the type three secretion system (T3SS) machinery and effectors. We tested a small-molecule compound, SE-1 (formerly designated OSSL_051168), which we had identified as an effective inhibitor of the AraC family proteins RhaS and RhaR, for its ability to inhibit VirF. Cell-based reporter gene assays with Escherichia coli and Shigella, as well as in vitro DNA binding assays with purified VirF, demonstrated that SE-1 inhibited DNA binding and transcription activation (likely by blocking DNA binding) by VirF. Analysis of mRNA levels using real-time quantitative reverse transcription-PCR (qRT-PCR) further demonstrated that SE-1 reduced the expression of the VirF-dependent virulence genes icsA, virB, icsB, and ipaB in Shigella. We also performed eukaryotic cell invasion assays and found that SE-1 reduced invasion by Shigella. The effect of SE-1 on invasion required preincubation of Shigella with SE-1, in agreement with the hypothesis that SE-1 inhibited the expression of VirF-activated genes required for the formation of the T3SS apparatus and invasion. We found that the same concentrations of SE-1 had no detectable effects on the growth or metabolism of the bacterial cells or the eukaryotic host cells, respectively, indicating that the inhibition of invasion was not due to general toxicity. Overall, SE-1 appears to inhibit transcription activation by VirF, exhibits selectivity toward AraC family proteins, and has the potential to be developed into a novel antibacterial agent.

Shigella antigen-specific B memory cells are associated with decreased disease severity in subjects challenged with wild-type Shigella flexneri 2a

The role of Shigella-specific B memory (BM) in protection has not been evaluated in human challenge studies. We utilized cryopreserved pre- and post-challenge peripheral blood mononuclear cells and sera from wild-type Shigella flexneri 2a (wt-2457T) challenges. Challenged volunteers were either naïve or subjects who had previously ingested wt-2457T or been immunized with hybrid Escherichia coli-Shigella live oral candidate vaccine (EcSf2a-2). BM and antibody titers were measured against lipopolysaccharide (LPS) and recombinant invasion plasmid antigen B (IpaB); results were correlated with disease severity following challenge. Pre-challenge IgA IpaB-BM and post-challenge IgA LPS-BM in the previously exposed subjects negatively correlated with disease severity upon challenge. Similar results were observed with pre-challenge IgG anti-LPS and anti-IpaB titers in vaccinated volunteers. Inverse correlations between magnitude of pre-challenge IgG antibodies to LPS and IpaB, as well as IgA IpaB-BM and post-challenge IgA LPS-BM with disease severity suggest a role for antigen-specific BM in protection.

Molecular mechanisms of antibiotic resistance in diarrhoeagenic Escherichia coli isolated from children

Diarrhoeagenic Escherichia coli (DEC) are an important cause of diarrhoea in children and are associated with high antibiotic resistance. However, there are few studies on the molecular mechanisms of resistance in this group of bacteria. The aim of this study was to determine the mechanisms associated with antibiotic resistance in the most common phenotypes of DEC. A total of 369 E. coli strains [commensal strains and DEC from children with ('DEC-diarrhoea') or without ('DEC-control') diarrhoea] isolated from children aged <1 year in periurban districts of Lima, Peru, were analysed. In total, 154 ampicillin-resistant strains (36 commensals, 33 DEC-control and 85 DEC-diarrhoea) were studied by PCR for the most prevalent resistance mechanisms to ampicillin, trimethoprim/sulfamethoxazole (SXT), tetracycline and chloramphenicol as well as for integrase types 1 and 2. In addition, restriction fragment length polymorphism was performed for SXT-resistant strains. Commensal strains were more frequently resistant to nalidixic acid and ciprofloxacin (68% and 28%, respectively) than DEC strains (23% and 2%, respectively) (P<0.05). DEC-diarrhoea strains were more frequently SXT-resistant (78%) compared with DEC-control strains (65%) and commensal strains (60%) (P<0.05). The most frequent mechanisms of antibiotic resistance in DEC strains were: for β-lactams, bla(TEM) (31%; 37/118); for SXT, sul2 (48%; 49/103); for tetracycline, tetA (27%; 23/84); and for chloramphenicol, cat (80%; 28/35). The genes sul1 and dfrA1, related to SXT resistance, were more frequent in the DEC-diarrhoea group (41% and 28%, respectively) than in the other two groups (P<0.05). There was a high diversity of resistance genes in DEC, including symptomatic strains.

Natural products modulate Shigella-host-cell interaction

This study focused on identifying possible new options derived from natural sources for the treatment of bacterial infections. Several natural products were investigated for their potential in modulating Shigella-host-cell interactions. The proliferation of Shigella sonnei was effectively inhibited inside HEp-2 cells in the presence of 4-methoxycinnamic acid and propolin D. Propolin D also significantly reduced the apoptosis of infected macrophage-like U937 cells and moderately reduced the secretion of interleukin (IL)-1β and IL-18, which probably resulted from the inhibition of invasion plasmid antigen B secretion by this compound. Further characterization showed that propolin D did not prevent escape of Shigella from phagocytic vacuoles, as evidenced by actin-based motility and by the fact that addition of chloroquine did not further reduce the number of intracellular c.f.u. The role of propolin D in modulating autophagy could not be established under the experimental conditions used. As these compounds had no direct anti-Shigella activity in vitro, it was concluded that these compounds modulated Shigella-host-cell interactions by targeting yet-to-be defined mechanisms that provide benefits to host cells.

Etiology of diarrhea in young children and patterns of antibiotic resistance in Cambodia

BACKGROUND

Little is known about diarrhea etiology and antibiotic resistance in developing countries where diarrhea is a major public health problem.

METHODS

To describe diarrhea etiology and antibiotic resistance patterns in Cambodia, 600 children aged 3 months to 5 years with acute diarrhea (cases) and 578 children without diarrhea (controls) were enrolled from a hospital in Phnom Penh. Stool samples were collected, and pathogens and antibiotic resistance patterns were described.

RESULTS

The most frequently isolated pathogens in these cases were enteroaggregative Escherichia coli (20%) and rotavirus (26%). Enterotoxigenic E. coli, enteroaggregative E. coli, Shigella, Aeromonas, rotavirus, and adenovirus were statistically significantly associated with diarrhea. Among cases, vomiting was associated with viral infections, whereas bloody stool was associated with Shigella. Enterotoxigenic E. coli isolates were highly resistant to ampicillin, sulfonamides, and tetracycline. Approximately 50% of Campylobacter coli and 30% of Campylobacter jejuni isolates were resistant to nalidixic acid and ciprofloxacin. Over 33% of Salmonella isolates were resistant to ampicillin and tetracycline, and almost 100% of Shigella isolates were resistant to trimethoprim/sulfamethoxazole.

CONCLUSIONS

These data on the etiology of diarrhea and antibiotic resistance patterns in Cambodia will have significant effect on local public health policies and on local resource prioritization practices.

Antigen-specific IgA B memory cell responses to Shigella antigens elicited in volunteers immunized with live attenuated Shigella flexneri 2a oral vaccine candidates

We studied the induction of antigen-specific IgA memory B cells (B(M)) in volunteers who received live attenuated Shigella flexneri 2a vaccines. Subjects ingested a single oral dose of 10(7), 10(8) or 10(9) CFU of S. flexneri 2a with deletions in guaBA (CVD 1204) or in guaBA, set and sen (CVD 1208). Antigen-specific serum and stool antibody responses to LPS and Ipa B were measured on days 0, 7, 14, 28 and 42. IgA B(M) cells specific to LPS, Ipa B and total IgA were assessed on days 0 and 28. We show the induction of significant LPS-specific IgA B(M) cells in anti-LPS IgA seroresponders. Positive correlations were found between anti-LPS IgA B(M) cells and anti-LPS IgA in serum and stool; IgA B(M) cell responses to IpaB were also observed. These B(M) cell responses are likely play an important role in modulating the magnitude and longevity of the humoral response.

An update on management of severe acute infectious gastroenteritis in children

This article focuses on clinical and diagnostic aspects relevant to severe acute infectious gastroenteritis in children and will update treatment strategies focused on, although not limited to, anti-infective therapy. For the purposes of this article we will consider severe acute infectious gastroenteritis as follows: watery diarrhea accompanied by, or at high risk for, moderate to severe dehydration due to abrupt onset of vomiting that reduces oral intake, and/or frequent emission of liquid stools, or moderate to severe dysenteric/bloody diarrhea with moderate to high-grade fever. The article will not include food poisoning associated with bacterial toxins and will only briefly discuss oral rehydration strategies and intravenous solutions. The article will also briefly discuss current preventive measures against rotavirus gastroenteritis through vaccination, a topic that has been extensively discussed elsewhere.

Safety and immunogenicity of a Shigella flexneri 2a Invaplex 50 intranasal vaccine in adult volunteers

Shigellosis is a leading cause of diarrhea worldwide prompting vaccine development. The Shigella flexneri Invaplex 50 is a macromolecular complex containing IpaB, IpaC, and LPS, formulated from an aqueous extract of virulent Shigella delivered via nasal administration. Preclinical vaccine testing demonstrated safety, immunogenicity and efficacy. An open-label dose-escalating phase 1 study evaluated a 3-dose (2-week intervals) regimen via nasal pipette delivery. Thirty-two subjects were enrolled into one of four vaccine dose groups (10, 50, 240, or 480 microg). The vaccine was well tolerated with minor short-lived nasal symptoms without evidence of dose effect. Antibody-secreting cell (ASC) responses were elicited at doses > or =50 microg with the highest IgG ASC, Invaplex 50 (100%) and S. flexneri 2a LPS (71%), as well as, serologic responses (43%) occurring with the 240 microg dose. Fecal IgA responses, Invaplex 50 (38.5%) and LPS (30.8%), were observed at doses > or =240 microg. The Invaplex 50 nasal vaccine was safe with encouraging mucosal immune responses. Follow-on studies will optimize dose, delivery mechanism and assess efficacy in a S. flexneri 2a challenge study.

Review article: rifaximin, a minimally absorbed oral antibacterial, for the treatment of travellers' diarrhoea

BACKGROUND

Travellers' diarrhoea, a common problem worldwide with significant medical impact, is generally treated with anti-diarrhoeal agents and fluid replacement. Systemic antibiotics are also used in selected cases, but these may be associated with adverse effects, bacterial resistance and drug-drug interactions.

AIM

To review the clinical evidence supporting the efficacy and safety of the minimally absorbed oral antibiotic rifaximin in travellers' diarrhoea.

METHODS

PubMed and the Cochrane Register of Controlled Clinical Trials (to January 2010) and International Society of Travel Medicine congress abstracts (2003-2009) were searched to identify relevant publications.

RESULTS

A total of 10 publications were included in the analysis. When administered three times daily for 3 days, rifaximin is superior to placebo or loperamide; it is at least as effective as ciprofloxacin in reducing duration of illness and restoring wellbeing in patients with travellers' diarrhoea, both with and without identification of a pathogen, as well as in diarrhoea caused by Escherichia coli infection. Rifaximin demonstrates only minimal potential for development of bacterial resistance and for cytochrome P450-mediated drug-drug interactions, and its tolerability profile is similar to that of placebo.

CONCLUSION

When antibiotic therapy is warranted in uncomplicated travellers' diarrhoea, rifaximin may be considered as a first-line treatment option because of its favourable efficacy, tolerability and safety profiles.

Antigen-specific B memory cell responses to lipopolysaccharide (LPS) and invasion plasmid antigen (Ipa) B elicited in volunteers vaccinated with live-attenuated Shigella flexneri 2a vaccine candidates

We evaluated B memory responses in healthy adult volunteers who received one oral dose of live-attenuated Shigella flexneri 2a vaccine. LPS-specific B(M) cells increased from a median of 0 at baseline to 20 spot forming cells (SFC)/10(6) expanded cells following vaccination (p=0.008). A strong correlation was found between post-vaccination anti-LPS B(M) cell counts and peak serum anti-LPS IgG titers (rs=0.95, p=0.0003). Increases in B(M) specific for IpaB approaching significance were also observed. In sum, oral vaccination with live-attenuated S. flexneri 2a elicits B(M) cells to LPS and IpaB, suggesting that B(M) responses to Shigella antigens should be further studied as a suitable surrogate of protection in shigellosis.

Shigella flexneri type III secretion system effectors OspB and OspF target the nucleus to downregulate the host inflammatory response via interactions with retinoblastoma protein

OspF, OspG and IpaH(9.8) are type III secretion system (T3SS) effectors of Shigella flexneri that downregulate the host innate immune response. OspF modifies mitogen-activated protein kinase pathways and polymorphonuclear leucocyte transepithelial migration associated with Shigella invasion. OspF also localizes in the nucleus to mediate chromatin remodelling, resulting in reduced transcription of inflammatory cytokines. We now report that OspB can be added to the set of S. flexneri T3SS effectors required to modulate the innate immune response. T84 cells infected with a Delta ospB mutant resulted in reduced polymorphonuclear leucocyte transepithelial migration and mitogen-activated protein kinase signalling. Tagged versions of OspB localized with endosomes and the nucleus. Further, T84 cells infected with the Delta ospB mutant showed increased levels of secreted IL-8 compared with wild-type infected cells. Both GST-OspB and GST-OspF coprecipitated retinoblastoma protein from host cell lysates. Because Delta ospB and Delta ospF mutants share similar phenotypes, and OspB and OspF share a host binding partner, we propose that OspB and OspF facilitate the remodelling of chromatin via interactions with retinoblastoma protein, resulting in diminished inflammatory cytokine production. The requirement of multiple T3SS effectors to modulate the innate immune response correlates to the complexity of the human immune system.

Immunogenicity and protective efficacy of recombinant Campylobacter jejuni flagellum-secreted proteins in mice

Immunogenicity and protective efficacy of three Campylobacter jejuni flagellum-secreted proteins, FlaC, FspA1, and FspA2, were compared by use of a mouse model. Mice were immunized intranasally with each protein with or without LTR192G as the adjuvant and challenged intranasally with C. jejuni 81-176 or CG8486. All three proteins were immunogenic, although FspA1 induced the highest levels of serum immunoglobulin G (IgG) and fecal IgA. Although immunogenic, FlaC provided only 18% protection against disease from C. jejuni 81-176. Immunization with FspA1 resulted in 57.8% protection without adjuvant or 63.8% protection with adjuvant against homologous challenge with 81-176. Alternatively, immunization with FspA2 provided 38.4% (without adjuvant) or 47.2% (with adjuvant) protection against disease from homologous challenge with CG8486. In contrast to FspA2, FspA1 provided some heterologous protection against C. jejuni CG8486 when delivered with (31.2%) or without (44.8%) LTR192G. These results suggest that FspA1 may be a good subunit vaccine candidate against C. jejuni disease.

Changes in tetracycline susceptibility of enteric bacteria following switching to nonmedicated milk replacer for dairy calves

A randomized intervention study was conducted to determine if discontinuing use of calf milk replacer medicated with oxytetracycline results in increased tetracycline susceptibility in Salmonella and Campylobacter spp. and Escherichia coli in dairy calves over a 12-month period. Dairy herds with enteric bacteria with known low tetracycline susceptibility were enrolled for the study. Fecal samples from preweaned calves and environmental samples were collected from eight dairy herds in Michigan and New York State. Samples were collected monthly for 3 months prior to and 12 months after four of the eight herds discontinued medicated milk replacer feeding. Salmonella and Campylobacter spp. and E. coli were isolated, and antimicrobial susceptibility testing was conducted using automated broth microdilution. A total of 804 intervention and 1,026 control calf fecal samples and 122 intervention and 136 control environmental samples were collected for testing. No differences in owner-reported morbidity and mortality between treatment groups were seen. The intervention was significantly associated with increasing tetracycline susceptibility in E. coli and Salmonella. Tetracycline susceptibility increased in intervention herds for the first 3 months after switching to nonmedicated milk replacer but declined in subsequent months. Discontinuing the practice of feeding medicated milk replacers to calves increased tetracycline susceptibility in E. coli and Salmonella on dairy farms, without increasing cattle disease, but declines in effectiveness after 3 months suggest that other factors contribute to decreasing susceptibility on the farm.

Development of a travelers' diarrhea vaccine for the military: how much is an ounce of prevention really worth?

Infectious diarrhea is one of the many threats to the deployed military, and given limited resources, a decision to pursue a vaccine acquisition strategy should be based on best evidence that weighs costs and benefits compared to alternatives. An economic model was developed to estimate the marginal cost to avert a duty day lost due to diarrhea for a vaccine acquisition strategy compared to current clinical management, for both multiplex and pathogen-specific vaccines. Vaccines against Campylobacter and enterotoxigenic Escherichia coli appeared to be more favorable than a Shigella vaccine. This model provides an evidence-based decision tool to support prioritization in vaccine development.

The NleE/OspZ family of effector proteins is required for polymorphonuclear transepithelial migration, a characteristic shared by enteropathogenic Escherichia coli and Shigella flexneri infections

Enteropathogenic Escherichia coli (EPEC) and Shigella flexneri are human host-specific pathogens that infect intestinal epithelial cells. However, each bacterial species employs a different infection strategy within this environmental niche. EPEC attaches to the apical surface of small intestine enterocytes, causing microvillus effacement and rearrangement of the host cell cytoskeleton beneath adherent bacteria. In contrast, S. flexneri invades the large intestine epithelium at the basolateral membrane, replicates, and spreads cell to cell. Both EPEC and S. flexneri rely on type three secretion systems (T3SS) to secrete effectors into host cells, and both pathogens recruit polymorphonuclear leukocytes (PMNs) from the submucosa to the lumen of the intestine. In this report, we compared the virulence functions of the EPEC T3SS effector NleE and the homologous Shigella protein Orf212. We discovered that Orf212 was secreted by the S. flexneri T3SS and renamed this protein OspZ. Infection of polarized T84 intestinal epithelial cells with an ospZ deletion mutant of S. flexneri resulted in reduced PMN transepithelial migration compared to infection by the wild type. An nleE deletion mutant of EPEC showed a similar reduction of PMN migration. The ability to induce PMN migration was restored in both mutants when either ospZ or nleE was expressed from a plasmid. An infection of T84 cells with the delta ospZ mutant resulted in reduced extracellular signal-related kinase phosphorylation and NF-kappaB activation compared to infection with the wild type. Therefore, we conclude that OspZ and NleE have similar roles in the upstream induction of host signaling pathways required for PMN transepithelial migration in Shigella and EPEC infections.

Campylobacter jejuni proteomics for new travellers’ diarrhoea vaccines

Travellers' diarrhoea is defined as diarrhoea that develops while a person is abroad in or shortly after return from a developing country. Different pathogens cause diarrhoea in travellers. Campylobacter jejuni is one of the most prominent agents for this illness. Diarrhoea is defined as an abnormally increased frequency or decreased consistency of stools for less than one week. Antibiotics are effective in preventing travellers' diarrhoea, but routine prophylaxis with antibiotics, should be discouraged. Vaccination is promising but no vaccine against C. jejuni is available at the moment. This article presents the ACE BioSciences strategy for the discovery of protein based vaccine candidates using a cell surface proteomics approach of C. jejuni. New targets for C. jejuni protein vaccines were identified. As proof of concept, we could demonstrate decreased colonization of C. jejuni in mice after vaccination with some of these candidates. It is likely that the proteomics based ACE-Biosciences approach will result in reliable travellers' diarrhoea protein-vaccines in the future.

OspF and OspC1 are Shigella flexneri type III secretion system effectors that are required for postinvasion aspects of virulence

Shigella flexneri is the causative agent of dysentery, and its pathogenesis is mediated by a type III secretion system (T3SS). S. flexneri secretes effector proteins into the eukaryotic cell via the T3SS, and these proteins usurp host cellular functions to the benefit of the bacteria. OspF and OspC1 are known to be secreted by S. flexneri, but their functions are unknown. We transformed S. flexneri with a plasmid that expresses a two-hemagglutinin tag (2HA) in frame with OspF or OspC1 and verified that these proteins are secreted in a T3SS-dependent manner. Immunofluorescence of HeLa cells infected with S. flexneri expressing OspF-2HA or OspC1-2HA revealed that both proteins localize in the nucleus and cytoplasm of host cells. To elucidate the function of these T3SS effectors, we constructed DeltaospF and DeltaospC1 deletion mutants by allelic exchange. We found that DeltaospF and DeltaospC1 mutants invade host cells and form plaques in confluent monolayers similar to wild-type S. flexneri. However, in the polymorphonuclear (PMN) cell migration assay, a decrease in neutrophil migration was observed for both mutants in comparison to the migration of wild-type bacteria. Moreover, infection of polarized T84 intestinal cells infected with DeltaospF and DeltaospC1 mutants resulted in decreased phosphorylation of extracellular signal-regulated kinase 1/2 in comparison to that of T84 cells infected with wild-type S. flexneri. To date, these are the first examples of T3SS effectors implicated in mitogen-activated protein kinase kinase/extracellular signal-regulated kinase pathway activation. Ultimately, OspF and OspC1 are essential for PMN transepithelial migration, a phenotype associated with increased inflammation and bacterial access to the submucosa, which are fundamental aspects of S. flexneri pathogenesis.

The use of systemic fluoroquinolones

The only indications for which a fluoroquinolone (ie, ciprofloxacin) is licensed by the US Food and Drug Administration for use in patients younger than 18 years are complicated urinary tract infections, pyelonephritis, and postexposure treatment for inhalation anthrax. Nonetheless, approximately 520,000 prescriptions for fluoroquinolones were written in the United States for patients younger than 18 years in 2002; 13,800 were written for infants and children 2 to 6 years of age, and 2750 were written for infants younger than 2 years. Clinical trials of fluoroquinolones in pediatric patients with various diagnoses have been published and are reviewed. Fluoroquinolones cause arthrotoxicity in juvenile animals and have been associated with reversible musculoskeletal events in both children and adults. Other adverse events associated with fluoroquinolones include central nervous system disorders, photosensitivity, disorders of glucose homeostasis, prolongation of QT interval with rare cases of torsade de pointes (often lethal ventricular arrhythmia in patients with long QT syndrome), hepatic dysfunction, and rashes. The increased use of fluoroquinolones in adults has resulted in increased bacterial resistance to this class of antibacterial agents. This report provides specific guidelines for the systemic use of fluoroquinolones in children. Fluoroquinolone use should be restricted to situations in which there is no safe and effective alternative to treat an infection caused by multidrug-resistant bacteria or to provide oral therapy when parenteral therapy is not feasible and no other effective oral agent is available.

Surveillance uncovers the smoking gun for resistance emergence

Today, antibiotic resistance is becoming a major healthcare concern. As global travel increases, more antibiotic-resistant bacteria will be disseminated from one country to another, thereby imposing a problem worldwide. Since the development of resistance is an evolutionary process, constant surveillance is needed to gain insight into the problem and surveillance studies needed to document the spread of antibiotic resistance. The basic objectives of surveillance studies in antimicrobial resistance are: to determine the level of resistance in a particular geographical area; to monitor changes in the level of resistance and make this information available to therapeutic policy-makers, as well as to detect new mechanisms of resistance for use as early warning signs; to study how such resistance develops, persists and spreads, and to monitor interventions. Although, surveillance provides the smoking gun for emergence of antibiotic resistance, improvement of the system is necessary and may be achieved through enhanced information technology and diagnostic tools.