Aeromonas infection of the hepatobiliary system: report of 15 cases and review of the literature

First report of multidrug-resistant carbapenemase-producing Aeromonas caviae co-harboring mcr-3.43 and mcr-7.2

Hospital sewage serves as a crucial reservoir for antibiotic resistance genes. As colistin and carbapenems are the last-resort antibiotics, the emergence of their resistance genes has become a significant concern in clinical settings. In this study, we found that two novel mcr alleles (mcr-3.43 and mcr-7.2) with two carbapenemase genes (blaNDM-1 and blaKPC-2) were encoded in a single Aeromonas caviae strain isolated from hospital sewage. Our phylogenetic analysis revealed that the mcr-3.43 gene clustered with mcr-3.17 (with 95.55% amino acid identity), while the mcr-7.2 gene clustered with mcr-7.1 (with 68.68% amino acid identity). BLAST search against GenBank showed that mcr-7.2 was exclusively detected in Aeromonas spp. Mobile genetic elements were not found in the genetic context of mcr-7.2, suggesting that the dissemination of mcr-7.2 in Aeromonas spp. may be dependent on vertical transfer or recombination. The blaNDM-1 was adjacent to a recombinase gene and flanked by two IS91 elements, indicating a potential mobilization mechanism mediated by recombination and/or ISs. The blaKPC-2 gene was located on an IncU plasmid and adjacent to an ISKpn6. In summary, our study provides evidence for Aeromonas spp. as one of the potential reservoirs of colistin and carbapenem resistance genes.IMPORTANCEThe study discovered two novel mcr genes (mcr-3.43 and mcr-7.2) and two carbapenemase genes (blaNDM-1 and blaKPC-2) in a single Aeromonas caviae strain retrieved from hospital sewage. Using phylogenetic analysis and comparative data evaluation, the study revealed the genetic relatedness and dissemination potential of the detected resistance genes. With the exclusive discovery that mcr-7.2 is only present in Aeromonas spp. and the lack of mobile genetic elements in its genetic context, there is a strong indication of limited dissemination. The identification of these four resistance genes in a single strain of Aeromonas provided valuable insights into their potential presence in this genus. This study revealed that hospital sewage functions as a significant reservoir for antibiotic resistance genes, including colistin and carbapenem resistance genes.

Antimicrobial resistance in aeromonads and new therapies targeting quorum sensing

Aeromonas species (spp.) are well-known fish pathogens, several of which have been recognized as emerging human pathogens. The organism is capable of causing a wide spectrum of diseases in humans, ranging from gastroenteritis, wound infections, and septicemia to devastating necrotizing fasciitis. The systemic form of infection is often fatal, particularly in patients with underlying chronic diseases. Indeed, recent trends demonstrate rising numbers of hospital-acquired Aeromonas infections, especially in immuno-compromised individuals. Additionally, Aeromonas-associated antibiotic resistance is an increasing challenge in combating both fish and human infections. The acquisition of antibiotic resistance is related to Aeromonas' innate transformative properties including its ability to share plasmids and integron-related gene cassettes between species and with the environment. As a result, alternatives to antibiotic treatments are desperately needed. In that vein, many treatments have been proposed and studied extensively in the fish-farming industry, including treatments that target Aeromonas quorum sensing. In this review, we discuss current strategies targeting quorum sensing inhibition and propose that such studies empower the development of novel chemotherapeutic approaches to combat drug-resistant Aeromonas spp. infections in humans. KEY POINTS: • Aeromonas notoriously acquires and maintains antimicrobial resistance, making treatment options limited. • Quorum sensing is an essential virulence mechanism in Aeromonas infections. • Inhibiting quorum sensing can be an effective strategy in combating Aeromonas infections in animals and humans.

Good Performance of Revised Scoring Systems in Predicting Clinical Outcomes of Aeromonas Bacteremia in the Emergency Department: A Retrospective Observational Study

BACKGROUND

Aeromonas species, Gram-negative, non-sporulating, facultative, and anaerobic bacilli, widely distributed in aquatic environments, derive various infections, including bacteremia. Most of these infections were opportunistic and found in patients with predisposing conditions. Among the infections, bacteremia remains with notable mortality, reported from 15% to 45%. However, predicting systems for assessing the mortality risk of this disease have yet to be investigated. We aimed to validate the performance of specific predictive scoring systems to assess the clinical outcomes of Aeromonas bacteremia and applied the revised systems to predict mortality risk.

METHODS

A retrospective observational study reviewed patients with bacteremia caused by Aeromonas spp. based on at least one positive blood culture sample collected in the emergency department from January 2012 to December 2020. The outcome was in-hospital mortality. We used seven predictive scoring systems to predict the clinical outcome. According to the effectiveness in predicting mortality, we revised three of the seven predictive scoring systems by specific characteristics to refine their risk-predicting performances.

RESULTS

We enrolled 165 patients with bacteremia caused by Aeromonas spp., including 121 males (73.3%) and 44 females (26.7%), with a mean age of 66.1 ± 14.9 years and an average length of hospital stay of 12.4 ± 10.9 days. The overall mortality rate was 32.7% (54/165). The non-survivors had significantly higher scores in MEDS (6.7 ± 4.2 vs. 12.2 ± 3.3, p < 0.001), NEWS (4.0 ± 2.8 vs. 5.3 ± 3.0, p = 0.008), and qSOFA (0.3 ± 0.6 vs. 0.6 ± 0.7, p = 0.007). Regarding mortality risk prediction, the MEDS demonstrated the best predictive power with AUC of ROC measured up to 0.834, followed by NEWS (0.626) and qSOFA (0.608). We revised the MEDS, NEWS, and qSOFA by hemoglobin and lactate. We found that the revised scores had better powerful performance, including 0.859, 0.767, and 0.691 of the AUC of ROC, if the revised MEDS ≥10, revised NEWS ≥8, and revised qSOFA ≥2, respectively.

CONCLUSIONS

MEDS, NEWS, and qSOFA were good tools for predicting outcomes in patients with Aeromonas spp. bacteremia. The revised MEDS, NEWS, and qSOFA demonstrated more powerful predicting performance than the original scoring systems. We suggested that patients with higher scores in revised MEDS (≥10), revised NEWS (≥8), and revised qSOFA (≥2) received early goal-directed therapy and appropriate broad-spectrum antibiotic treatment as early as possible to reduce mortality.

Clinical Features, Genome Epidemiology, and Antimicrobial Resistance Profiles of Aeromonas spp. Causing Human Infections: A Multicenter Prospective Cohort Study

Background

The genus Aeromonas is increasingly implicated in human infections, but knowledge of its clinical characteristics and antimicrobial resistance profiles has been limited owing to its complex taxonomy.

Methods

We conducted a multicenter prospective cohort study of patients with Aeromonas infections at hospitals across Japan. Patients were eligible for inclusion if they had an Aeromonas spp. strain in a clinical culture and were considered infected at the culture site. Clinical data were collected, and isolates underwent susceptibility testing and whole-genome sequencing.

Results

A total of 144 patients were included. Hepatobiliary infection accounted for a majority of infections (73% [105 of 144]), which mostly occurred in elderly patients with comorbid conditions, including hepatobiliary complications. The all-cause 30-day mortality rate was 10.0% (95% confidence interval, 4.9%-14.8%). By whole-genome sequencing, 141 strains (98%) belonged to 4 Aeromonas species-A caviae, A hydrophila, A veronii, and A dhakensis-with significant intraspecies diversity. A caviae was predominant in all infection sites except skin and soft tissue, for which A hydrophila was the prevailing species. The genes encoding chromosomally mediated class B, C, and D β-lactamases were harbored by 92%-100% of the isolates in a species-specific manner, but they often lacked association with resistance phenotypes. The activity of cefepime was reliable. All isolates of A hydrophila and A dhakensis carried an mcr-3-like colistin resistance gene and showed reduced susceptibility to colistin.

Conclusions

Hepatobiliary tract was the most common infection site of Aeromonas spp., with A caviae being the dominant causative species. The resistance genotype and phenotype were often incongruent for β-lactam agents.

Enteric Aeromonas Infection: a Common Enteric Bacterial Infection with a Novel Infection Pattern Detected in an Australian Population with Gastroenteritis

Aeromonas species are emerging human enteric pathogens. However, they are currently not routinely detected in many diagnostic laboratories, and information regarding Aeromonas enteric infections detected using molecular methods is lacking. Here, we investigated the detection of Aeromonas species and four other enteric bacterial pathogens in 341,330 fecal samples from patients with gastroenteritis processed in a large Australian diagnostic laboratory between 2015 and 2019. These enteric pathogens were detected using quantitative real-time PCR (qPCR) methods. Furthermore, we compared the qPCR cycle threshold (CT) values obtained from fecal samples that tested positive for Aeromonas only by molecular detection with those of samples that tested positive by both molecular detection and bacterial isolation methods. Aeromonas species were found to be the second most common bacterial enteric pathogens among patients with gastroenteritis. We observed a unique pattern of three infection peaks for Aeromonas, which correlated with the age of the patients. Aeromonas species were the most common enteric bacterial pathogens in children younger than 18 months. Fecal samples that tested positive for Aeromonas only by molecular detection had significantly higher CT values than fecal samples that tested positive by both molecular detection and bacterial culture. In conclusion, our findings reveal that Aeromonas enteric pathogens exhibit an age-related three-peak infection pattern, distinguishing them from other enteric bacterial pathogens. Moreover, the high rate of Aeromonas enteric infection discovered in this study suggests that Aeromonas species should be routinely tested in diagnostic laboratories. Our data also show that combining qPCR with bacterial culture can enhance the detection of enteric pathogens. IMPORTANCE Aeromonas species are emerging human enteric pathogens. However, these species are currently not routinely detected in many diagnostic laboratories, and no studies have reported the detection of Aeromonas enteric infection using molecular methods. We investigated the presence of Aeromonas species and four other enteric bacterial pathogens in 341,330 fecal samples from patients with gastroenteritis using quantitative real-time PCR (qPCR) methods. Interestingly, we discovered that Aeromonas species were the second most common bacterial enteric pathogens in patients with gastroenteritis, exhibiting a novel infection pattern compared to those of other enteric pathogens. Furthermore, we found that Aeromonas species were the most prevalent enteric bacterial pathogens in children aged 6 to 18 months. Our data also revealed that qPCR methods exhibit higher sensitivity in detecting enteric pathogens compared to that of bacterial culture alone. Moreover, combining qPCR with bacterial culture enhances the detection of enteric pathogens. These findings emphasize the importance of Aeromonas species in public health.

Infections caused by Aeromonas species in hospitalized patients: A case series

The Aeromonads are ubiquitous Gram-negative bacilli that cause community acquired, and healthcare associated infections. In this retrospective study we analysed clinical and microbiological characteristics of thirty-six culture proven Aeromonas infections. The most common species isolated was A.hydrophila. Clinical presentation included syndromes like skin and soft tissue infections (SSTI), urinary tract infections, and central line associated bloodstream infections (CLABSI). Most of the isolates were sensitive to aminoglycosides [97.2%], followed by 3 rd generation cephalosporins, quinolones and carbapenems. Overall mortality was 13.88% (5 out of 36 patients). A high index of suspicion is required for diagnosis and better outcomes.

The dietary supplementation of zinc oxide and selenium nanoparticles enhance the immune response in freshwater fish Oreochromis mossambicus against aquatic pathogen Aeromonas hydrophila

BACKGROUND

Green nanoparticles are subjected as an immunostimulant against bacterial pathogens.

METHODS

Murraya koenigii berry extract-based synthesized zinc oxide nanoparticles (Mb-ZnO NPs) and selenium nanoparticles (Mb-Se NPs) were relatively analyzed for immunostimulation in serum and mucus fish Oreochromis mossambicus against Aeromonas hydrophila infections. Initial minimum inhibitory concentration (MIC) was determined for both Mb-ZnO NPs and Mb-Se NPs followed by specific growth rate (SGR), antioxidant level (Superoxide dismutase activity (SOD), Catalase activity (CA), and Glutathione peroxidase activity (GPx)), and immune parameters Myeloperoxidase activity (MPO), Respiratory burst activity (RBA), Lysozyme activity (LYZ), Alkaline phosphatase activity (ALP), Serum antiprotease activity and Natural complement activity (NAC).

RESULTS

The potential bacterial inhibition property of Mb-ZnO NPs and Mb-Se NPs exhibited the most negligible concentration of 25 and 15 μg mL^-1, respectively, against A. hydrophila. In addition, Mb-ZnO NPs and Mb-Se NPs exhibited 70-80 % and 90-95 % diminished biofilm activity at 50 μg mL^-1 that was viewed under an inverted research microscope and confocal laser scanning microscopy (CLSM). Protein leakage and nucleic acid leakage assay quantified oozed out protein and nucleic acid from A. hydrophila that confirms Mb-Se NPs exhibited vigorous antibacterial activity than Mb-ZnO NPs at tested concentrations. Oreochromis mossambicus fed with Mb-ZnO NPs and Mb-Se NPs supplemented diet at different concentrations (0.5 mg/kg, 1 mg/kg and 2 mg/kg) improved SGR along with a rise in the immune response of those fishes against A. hydrophila infection. Serum and mucus of fish fed with Mb-Se NPs supplemented diet exhibited a significant rise in antioxidant level SOD, CA and GPx at a dosage of 2 mg/kg. Likewise, lipid peroxidation assay detected significantly diminished oxidative stress in the serum and mucus of fish fed with Mb-Se NPs supplemented diet (2 mg/kg). Enhanced immune parameters in serum and mucus of fish fed with Mb-Se NPs supplemented diet determined by MPO, RBA, LYZ, ALP, Serum antiprotease activity and NAC.

CONCLUSION

Thus O. mossambicus fed with Mb-Se NPs supplemented diet was less prone to become infected by aquatic pathogen A. hydrophila established by challenge study. On the whole, Mb-Se NPs supplemented diet ensured the rise in antioxidant response that boosts the immune responses and reduces the chance of getting infected against A. hydrophila infections.

Microbiological analysis of patients with first and recurrent episodes of acute cholangitis in a middle-sized hospital: A single-center retrospective study in rural North Kyoto, Japan

BACKGROUND

Knowledge of the bacterial spectrum involved in acute cholangitis is essential for adequate empiric antibiotic treatment. There is a lack of published data comparative data between patients with first and recurrent episodes of acute cholangitis. This study aimed to analyze the microbial spectrum in patients with first and second episodes of acute cholangitis.

METHODS

We retrospectively assessed 251 patients with first episodes of acute cholangitis between January 2014 to September 2020.

RESULTS

At the first episode of acute cholangitis, the predominant strains belonged to Escherichia coli (17.9%), followed by Klebsiella spp. (15.5%), Enterobacter spp. (6.4%), and Enterococcus spp. (5.6%). During follow-up, acute cholangitis recurred in 109 patients; at the second episode, the predominant strains belonged to Enterococcus spp. (35.8%), followed by Klebsiella spp. (27.5%), Enterobacter spp. (22.9%), and Escherichia coli (15.6%). Enterococcus spp. were the most common pathogen in patients with second episode of acute cholangitis, regardless of whether the cholangitis was caused by a malignant tumor or a benign disease.

CONCLUSIONS

Unlike in patients with a first episode of acute cholangitis, clinicians should consider empirical treatment with anti-enterococcal antibiotics in patients with recurrent episodes of acute cholangitis.

The Isolation of Aeromonas Species and Other Common Enteric Bacterial Pathogens from Patients with Gastroenteritis in an Australian Population

Aeromonas species are emerging human enteric pathogens. However, systematic analysis of Aeromonas species infection in human gastroenteritis in comparison with other enteric bacterial pathogens in the Australian population is lacking. Here we analysed the isolation of Aeromonas species and other bacterial pathogens in five consecutive years (2015–2019) from 375,842 stool samples of patients with gastroenteritis in a large Australian diagnostic laboratory and identified a subset (48 isolates) of Aeromonas isolates to species level, using multilocus phylogenetic analysis. Aeromonas species were the third most common bacterial pathogens, following Campylobacter and Salmonella species. Aeromonas infection rate was significantly correlated with increasing age (p < 0.001). Aeromonas species were more often isolated in warm seasons and in males than females (p < 0.001). Five Aeromonas species were identified. Most of the infections were from three species, namely Aeromonas veronii (52%), Aeromonas caviae (27%) and Aeromonas hydrophila (12.5%). The majority of patients with Aeromonas species infection did not have a documented overseas travel history. The findings from this study support the importance of Aeromonas species in human gastroenteritis and suggest that the sources of Aeromonas infection in Australian patients should be further investigated.

Urinary tract infection due to Aeromonas species: An uncommon causative agent

BACKGROUND

Members of the genus Aeromonas are Gram-negative bacilli, belonging to family Aeromonadaceae, and are widely found in various aquatic environments. The most common species associated with human infections are A. hydrophila, A. caviae, and A. veronii biovar sobria. Aeromonas species are recognized as emerging opportunistic pathogens in humans mainly causing gastrointestinal infections and wound infections with or without progression to septicaemia. Aeromonas organisms rarely cause urinary tract infection (UTI) and are not known uropathogens.

CASE

We report a series of UTI due to Aeromonas species in three adult patients, specifically identified as A. veronii biovar sobria in two patients and A. hydrophila in one patient. Two patients had history of occupational exposure to aquatic environment.

CONCLUSIONS

The cases highlight another expanded range of infections caused by Aeromonas spp. that can be encountered in a community setting and indicate that infections with Aeromonas spp. should be kept in mind while investigating for the etiology of UTI, especially in adult patients with occupational exposure to aquatic ecosystems.

<b><i>Aeromonas hydrophila</i></b> Panophthalmitis in Pemphigus Vulgaris: A Case Report

A 47-year-old Thai man, who had recently been diagnosed with active pemphigus vulgaris (PV) and treated with oral prednisolone together with intravenous dexamethasone, presented with severe ocular pain and light perception vision of the left eye for 4 days. Ophthalmic examination revealed periorbital soft tissue swelling with marked intraocular inflammation in the left eye. Severe panophthalmitis was diagnosed. Enucleation was performed after failure of intravenous antibiotics administration. Vitreous culture revealed <i>Aeromonas hydrophila</i> but no primary source of infection was clearly identified. An immunocompromised status accompanied with corticosteroid treatment is a risk factor for septicemia. <i>A. hydrophila</i>panophthalmitis was detected in the PV patient, and this organism caused a rapid disease progression with poor visual prognosis.

Severe acute cellulitis and sepsis caused by Aeromonas spp. in a dog on immunosuppressive therapy

OBJECTIVE

To describe the clinical presentation, diagnostic investigation, and medical management of a dog on immunosuppressive therapy that developed a severe soft tissue infection attributed to Aeromonas hydrophila/caviae.

CASE SUMMARY

A 5-year-old female neutered Border Collie dog was presented for investigation of a rapidly growing skin lesion. The dog had been diagnosed with immune-mediated thrombocytopenia and was receiving immunosuppressive therapy for 5 weeks. Physical examination at initial presentation revealed no abnormalities except a 6 cm raised, erythematous, firm, and painful swelling on the ventral abdomen. Within 12 hours of admission, the lesion had expanded to cover much of the ventrum and some areas had begun to slough. The patient had also become obtunded and exhibited pyrexia, tachypnea, tachycardia as well as extreme pain around the lesion. The dog's clinical signs and hematology results were consistent with sepsis. Histopathology showed severe acute suppurative cellulitis and panniculitis and a heavy growth of A. hydrophila/caviae was obtained on tissue culture. The infection was treated with trimethoprim sulphadiazine, based on culture and susceptibility results.

UNIQUE INFORMATION PROVIDED

This is the first reported case of severe panniculitis and cellulitis caused by Aeromonas spp. in a dog. Aeromonas spp. should be considered a differential diagnosis for cases of severe soft tissue infection, especially in immune-compromised animals or those with a history of aquatic exposure.

Aeromonas veronii biovar veronii and sepsis-infrequent complication of biliary drainage placement: A case report

BACKGROUND

Aeromonas species are uncommon pathogens in biliary sepsis and cause substantial mortality in patients with impaired hepatobiliary function. Asia has the highest incidence of infection from Aeromonas, whereas cases in the west are rare.

CASE SUMMARY

We report the case of a 64-year-old woman with advanced pancreatic cancer and jaundice who manifested fever, abdominal pain, severe thrombocytopenia, anemia and kidney failure following the insertion of a percutaneous transhepatic biliary drainage. Blood culture results revealed the presence of Aeromonas veronii biovar veronii (A. veronii biovar veronii). After antibiotic therapy and transfusions, the life-threatening clinical conditions of the patient improved and she was discharged.

CONCLUSION

This was a rare case of infection, probably the first to be reported in West countries, caused by A. veronii biovar veronii following biliary drainage. A finding of Aeromonas must alert clinician to the possibility of severe sepsis.

Clinical significance and outcome of Aeromonas spp. infections among 204 adult patients

The objectives of this investigation were to analyze the clinical patterns, risk groups, prognostic factors, and mortality of infections caused by Aeromonas spp. This was a retrospective study of adult patients with Aeromonas spp. isolates attended at the Hospital del Mar in Barcelona, Spain, between January 2006 and December 2012. Epidemiological data, antimicrobial susceptibility, clinical patterns, underlying illnesses, type of infection, admission to the intensive care unit (ICU), number of episodes, coinfection, antimicrobial therapy, and evolution were analyzed. A total of 221 clinical samples from 204 patients were positive for Aeromonas spp. The mean age of the patients was 67.6 years. The main clinical form of presentation was gastrointestinal (78.4%). Malignancy was the main risk group in 69 (33.8%) patients, and 48 (23.5%) were previously healthy. Twenty-one patients (10.3%) were admitted to the ICU. Infections were acquired in the hospital in 52.5% of the patients, and 28.9% were polymicrobial. The overall mortality (after 1 year of follow-up from the first positive culture) was 26.5%. Univariate analysis identified an association between increased mortality and the following variables: age ≥80 years, hospitalization, admission to the ICU, malignancy, extraintestinal infection, and appropriate antimicrobial therapy. In the multivariate analysis, age ≥80 years [odds ratio (OR), 4.37 [95% confidence interval (CI), 1.68-11.35; p = 0.002]], admission to the ICU (OR, 6.59 [95% CI, 2.17-19.99; p = 0.001]), and malignancy (OR, 3.62 [95% CI, 1.32-9.90; p = 0.012]) were significantly associated with mortality. Aeromonas infections are mainly gastrointestinal. The 1-year follow-up mortality rate was high. Old age (age ≥80 years), admission to the ICU, and malignancy were identified as independent risk factors for mortality.

Gastrointestinal Infections

Gastrointestinal infections in the immunocompromised host are caused by the common bacterial, viral, fungal, and parasitic agents that also cause infections in the immunocompetent host. Of special consideration is that immunocompromised patients may be at increased risk for infection or disease severity and by pathogens not seen in the competent host. This chapter reviews the various agents, risk factors, and diagnostic approaches to detect gastrointestinal infections in this patient population.

Multifocal Aeromonas Osteomyelitis in a Child with Leukemia

Aeromonas hydrophila is a Gram negative organism causing both intestinal and extraintestinal disease. The case of a 14-year-old girl with underlying immunodeficiency and leukemia who developed systemic A. hydrophila infection is described in this report. While in deep bone marrow aplasia she developed fever, severe pain in the lower extremities, and swelling of the left femur. Blood culture showed Escherichia coli and A. hydrophila whereas pus culture from the soft tissue swelling showed the presence of A. hydrophila. Imaging studies showed diffuse osteolytic lesions. Patient received 5 months of intravenous and oral antibiotics and she improved clinically whereas the radiology findings persisted.

Ocorrência de Aeromonas spp. em alimentos de origem animal e sua importância em saúde pública

Aeromonas spp. são bactérias Gram negativas, opor-tunistas, de natureza ubíqua, isoladas principalmente de amostras de água. Até o presente momento foram reconhecidas 31 espé-cies, sendo as de maior importância médica Aeromonas hydrophila, Aeromonas caviae e Aeromonas veronii. A patogenicidade do gênero é considerada multifatorial, sendo este produtor de diversos tipos de toxinas e com envolvimento de outros fatores capazes de facilitar a penetração e o estabelecimento do agente no hospedeiro, causando doença. O objetivo desta revisão é elucidar o papel dos alimentos de origem animal como fontes de contaminação de bactérias do gênero Aeromonas para o ser humano. Isolamentos de aeromonas de diversos produtos de origem animal têm sido relatados, como carne, leite e seus derivados, além de frutos do mar, e em ambientes de processamento, como abatedouros, frigorífcos e laticínios. Tem-se buscado determinar fontes de contaminação dos alimentos, e a água foi definida como o principal disseminador. Aeromonas já foi defnida como sendo a causadora de diversas enfermidades, desde afecções gastrointestinais até casos de meningite e morte. Considerando os alimentos de origem animal como importantes veículos de transmissão para o ser humano e o reconhecimento da água como fonte de disseminação do agente, torna-se imprescindível o tratamento adequado da água utilizada nos estabelecimentos processadores de alimentos para a segurança alimentar.

Microbial Keratitis Due to Aeromonas Species at a Tertiary Eye Care Center in Southern India

PURPOSE

To review the incidence, microbiological profile, antibiogram, clinical course, treatment, and outcome in patients with microbial keratitis due to Aeromonas species at a tertiary eye care center in Southern India.

DESIGN

A retrospective, noncomparative study.

METHODS

This study included all patients of corneal ulcer with a significant growth of Aeromonas species on culture of corneal scrapings managed at an eye institute in India between January 2005 and October 2011. The patients underwent standard diagnostic microbiological evaluation, and their treatment was guided by microbiology results and clinical response to therapy. Data were analyzed for the incidence, predisposing factors, clinical picture, microbiology, and the treatment outcome.

RESULTS

Fifteen patients of microbial keratitis showed Aeromonas species to be the causative agent, constituting 0.5% of bacterial keratitis diagnosed during this period. Laboratory results showed that Aeromonas hydrophila was the predominant species isolated. Most of the isolates were susceptible to commonly used ocular antibiotics. Medical therapy resulted in resolution of infection in 9 (60%) of 15 cases. Five patients required application of cyanoacrylate tissue adhesive with bandage contact lens for corneal perforation. Two of the 5 patients needed penetrating keratoplasty for uncontrolled infection. Twelve of 15 patients had some local predisposing host factors for the infection.

CONCLUSIONS

Aeromonas species are uncommon but important causal agents of microbial keratitis. The organisms most often cause infection in individuals with local predisposing factors. Aeromonas hydrophila is the predominant species associated with keratitis. Although the organisms are susceptible to most antibiotics, a third of the patients required additional surgical intervention.

Biliary tract infections caused by Aeromonas species

This study investigated the clinical and microbiological characteristics of patients with Aeromonas infections of the biliary tract. Patients with bile cultures positive for Aeromonas species during the period July 2004 to December 2011 were identified from a computerized database of a hospital in Taiwan. Patients with Aeromonas infections of the biliary tract were further identified. During the study period, a total of 1,142 isolates of Aeromonas species were obtained from 750 patients. Of those patients, 91 (12.1 %) had Aeromonas infections of the biliary tract. The annual incidence (episodes per 10,000 patient-days) of biliary tract infections caused by all Aeromonas species was 0.31 in 2007, 0.12 in 2010, and 0.27 in 2011. A. hydrophila was the most common species isolated (n = 41, 45.1 %), followed by A. caviae (n = 30, 33.0 %), A. veronii biovar sobria (n = 15, 16.5 %), and A. veronii biovar veronii (n = 5, 5.5 %). The majority of patients (n = 77, 84.6 %) had polymicrobial infections. Hepatobiliary stones (n = 50, 54.9 %) and hepatobiliary cancer (n = 38, 41.8 %) were the most common underlying diseases, followed by diabetes mellitus (n = 29, 31.9 %) and liver cirrhosis (n = 7, 7.7 %). The in-hospital mortality rate was 8.8 %. Infection-related mortality was associated with underlying immunocompromised condition (p = 0.044) and use of mechanical ventilation (p = 0.004), but was not associated with inappropriate antibiotic usage or concomitant bacteremia (n = 8, 8.8 %). In conclusion, biliary tract infections caused by Aeromonas species are not uncommon and can develop in both immunocompromised and immunocompetent patients; however, patients with underlying hepatobiliary diseases are particularly susceptible to these infections.

Severe sepsis caused by Aeromonas hydrophila in a patient using tocilizumab: a case report

INTRODUCTION

Aeromonas species do not commonly cause disease in humans. However, when disease is seen, it often occurs in patients with underlying immunosuppression or malignancy and has a high fatality rate.

CASE PRESENTATION

A 72-year-old Japanese woman with rheumatoid arthritis treated with tocilizumab (which has an immunosuppressive effect) presented with severe epigastric pain. She had a fever with chills, hypotension and jaundice. She was diagnosed with acute suppurative cholangitis and treated with cefoperazone-sulbactam and an endoscopic drainage was performed. Jaundice was slightly improved, but the shock state and inflammatory reactions were prolonged as typical of septic shock. On the second day after admission, an electrocardiogram showed ST segment elevation and echocardiography showed ventricular wall dysfunction. Coronary arteries were patent in coronary angiography and she was diagnosed with stress-induced cardiomyopathy. Blood cultures showed Aeromonas hydrophila. A stool culture was negative for A. hydrophila. On day six, her white blood cell count and neutrophils were normalized and cefoperazone-sulbactam treatment was halted. Left ventricular function normalized on day twelve and a laparoscopic cholecystectomy for cholelithiasis was performed on the 16th day of hospitalization. A culture from the bile showed A. hydrophila. Eighteen days after surgery, tocilizumab treatment was restarted and there were no complications. Two months after restarting tocilizumab, our patient is stable without any serious events.

CONCLUSION

We present a rare case of A. hydrophila sepsis and acute suppurative cholangitis in an elderly patient with gallstones and rheumatoid arthritis using tocilizumab. This clinical course may suggest that preemptive treatment for cholelithiasis prior to using molecular-targeting agents might be feasible in elderly patients.

Aeromonas spp. clinical microbiology and disease

Members of the genus Aeromonas inhabit various aquatic environments and are responsible for, and are implicated in, a number of intestinal and extra-intestinal infections in humans as well as other animals. This review focuses on invasive human infection and disease and summarizes available findings regarding the microbiology and detection of Aeromonas spp., with emphasis on successful identification and diagnosis, and the control of disease in the population. Antimicrobial resistance and therapy of Aeromonas spp. is also discussed.

The genus Aeromonas: taxonomy, pathogenicity, and infection

Over the past decade, the genus Aeromonas has undergone a number of significant changes of practical importance to clinical microbiologists and scientists alike. In parallel with the molecular revolution in microbiology, several new species have been identified on a phylogenetic basis, and the genome of the type species, A. hydrophila ATCC 7966, has been sequenced. In addition to established disease associations, Aeromonas has been shown to be a significant cause of infections associated with natural disasters (hurricanes, tsunamis, and earthquakes) and has been linked to emerging or new illnesses, including near-drowning events, prostatitis, and hemolytic-uremic syndrome. Despite these achievements, issues still remain regarding the role that Aeromonas plays in bacterial gastroenteritis, the extent to which species identification should be attempted in the clinical laboratory, and laboratory reporting of test results from contaminated body sites containing aeromonads. This article provides an extensive review of these topics, in addition to others, such as taxonomic issues, microbial pathogenicity, and antimicrobial resistance markers.

Development of imipenem resistance in an Aeromonas veronii biovar sobria clinical isolate recovered from a patient with cholangitis

Several imipenem-susceptible and -resistant Aeromonas veronii biovar sobria isolates with different morphologies and antimicrobial susceptibilities recovered from bile samples of a patient with cholangitis were analysed. These isolates belonged to the same clone and the imipenem-resistant strains showed overexpression of the imiS gene, encoding a chromosomal carbapenemase. These results should make clinicians aware of the possible emergence of multidrug-resistant A. veronii biovar sobria, perhaps as a consequence of previous treatment of a urinary tract infection with amoxicillin plus clavulanic acid.

Surgical site infection due to Aeromonas species: report of nine cases and literature review

Gastrointestinal and wound infections are the most common clinical presentation of Aeromonas. Surgical site infections (SSIs) due to this microorganism are rare. We studied the clinical and microbiological characteristics of 9 cases that appeared at 2 Spanish hospitals and reviewed 15 cases available in the literature. All patients (including our cases) had gastrointestinal or biliary diseases. 21 patients (91.3%) developed SSIs after abdominal or pelvic surgery. The mean duration from surgery to the onset of wound infection was 2.2 d in our 9 patients. The infection was polymicrobial in 17 patients (77.2%) and 19 cases were nosocomial (95%). Clinical outcome of all cases was uniformly good after treatment except for 2 patients. Two patients were cured only with surgical drainage. In conclusion, SSIs due to Aeromonas species have a probable endogenous source after abdominal or pelvic surgery and the onset is rapid in most cases. Clinical outcome is good after antibiotic treatment but surgical drainage without antibiotic therapy can be sufficient to clear the infection in some cases.

Prospective nationwide study of Aeromonas infections in France

We report a systematic prospective multicenter nationwide study of clinical Aeromonas infections in France. During 6 months (May to October 2006), 78 cases of aeromonosis were reviewed for risk factors and clinical, microbiological, and antimicrobial susceptibility data. They included wound infections (44%), bacteremia (26%), enteritis (19%), respiratory tract infections (6%), and miscellaneous (5%) infections.

Molecular characterization of a functional type VI secretion system from a clinical isolate of Aeromonas hydrophila

Our laboratory recently molecularly characterized the type II secretion system (T2SS)-associated cytotoxic enterotoxin (Act) and the T3SS-secreted AexU effector from a diarrheal isolate SSU of Aeromonas hydrophila. The role of these toxin proteins in the pathogenesis of A. hydrophila infections was subsequently delineated in in vitro and in vivo models. In this study, we characterized the new type VI secretion system (T6SS) from isolate SSU of A. hydrophila and demonstrated its role in bacterial virulence. Study of the role of T6SS in bacterial virulence is in its infancy, and there are, accordingly, only limited, recent reports directed toward a better understanding its role in bacterial pathogenesis. We have provided evidence that the virulence-associated secretion (vas) genes vasH (Sigma 54-dependent transcriptional regulator) and vasK (encoding protein of unknown function) are essential for expression of the genes encoding the T6SS and/or they constituted important components of the T6SS. Deletion of the vasH gene prevented expression of the potential translocon hemolysin coregulated protein (Hcp) encoding gene from bacteria, while the vasK gene deletion prevented secretion but not translocation of Hcp into host cells. The secretion of Hcp was independent of the T3SS and the flagellar system. We demonstrated that secreted Hcp could bind to the murine RAW 264.7 macrophages from outside, in addition to its ability to be translocated into host cells. Further, the vasH and vasK mutants were less toxic to murine macrophages and human epithelial HeLa cells, and these mutants were more efficiently phagocytosed by macrophages. We also provided evidence that the expression of the hcp gene in the HeLa cell resulted in apoptosis of the host cells. Finally, the vasH and vasK mutants of A. hydrophila were less virulent in a septicemic mouse model of infection, and animals immunized with recombinant Hcp were protected from subsequent challenge with the wild-type (WT) bacterium. In addition, mice infected with the WT A. hydrophila had circulating antibodies to Hcp, indicating an important role of T6SS in the pathogenesis of A. hydrophila infections. Taken together, we have characterized the T6SS from Aeromonas for the first time and provided new features of this secretion system not yet known for other pathogens.

[Extraintestinal infection due to Aeromonas spp.: review of 38 cases]

INTRODUCTION

Aeromonas spp. typically cause gastroenteritis, but can occasionally produce extraintestinal infections. The aim of this study was to determine the clinical and microbiological characteristics of extraintestinal infections caused by Aeromonas spp. in our area.

PATIENTS AND METHODS

The clinical histories of patients with extraintestinal infections by Aeromonas spp. diagnosed in Hospital Universitario de Guadalajara (Guadalajara, Spain) from January 1990 to December 2005 were reviewed. Identification and susceptibility testing of the strains were performed by the MicroScan WalkAway-40 automated method (DadeBerhing).

RESULTS

Thirty-eight cases of extraintestinal infections were diagnosed: 18 abdominal infections, 11 skin and soft tissue infections, 3 urinary tract infections, and 3 episodes of bacteremia with no primary focus. The species most frequently found was A. hydrophila (16 cases). Infection occurred most often in patients with underlying diseases (76.3%), including malignancy (34.2%) and diabetes mellitus (21%). Polymicrobial infections were detected in 50% and the etiology was nosocomial in 21%. The mortality rate was 16.2%. Gentamicin, amikacin, cefotaxime and ciprofloxacin had the highest activity against the Aeromonas species isolated.

CONCLUSIONS

Aeromonas spp. as the causative infectious agent should be kept in mind in patients with infections of the biliary system, surgical wounds in the abdomen and posttraumatic cellulitis. Extraintestinal infection is usually polymicrobial, appears most commonly in patients with underlying diseases, and generally has a good prognosis. The most active antibiotics in vitro were gentamicin, amikacin, cefotaxime and ciprofloxacin.

Biological characterization of a new type III secretion system effector from a clinical isolate of Aeromonas hydrophila-part II

We recently identified a novel type III secretion system (T3SS) effector, AexU, from a diarrheal isolate SSU of Aeromonas hydrophila, and demonstrated that mice infected with the DeltaaexU mutant were significantly protected from mortality. Although the NH(2)-terminal domain of this toxin exhibits homology to AexT of A. salmonicida, a fish pathogen, and ExoT/S of Pseudomonas aeruginosa, the COOH-terminal domain of AexU is unique, with no homology to any known proteins in the NCBI database. In this study, we purified the full-length AexU and its NH(2)-terminal (amino acid residues 1-231) and COOH-terminal (amino acid residues 232-512) domains after expression of their corresponding genes in Escherichia coli as histidine-tag fusion proteins using the bacteriophage T7 RNA polymerase/promoter-based pET-30a vector system. The full-length and NH(2)- and COOH-terminal domains of AexU exhibited ADP-ribosyltransferase activity, with the former two exhibiting much higher activity than the latter. These different forms of AexU were also successfully expressed and produced in the HeLa Tet-Off cell system using a pBI-EGFP vector, as demonstrated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, Western blot analysis, and intracellular staining of the toxin using flow cytometric analysis. Production of AexU in HeLa cells resulted in possible actin reorganization and cell rounding, as determined by phalloidin staining and confocal microscopy. Based on electron microscopy, the toxin also caused chromatin condensation, which is indicative of apoptosis. Apoptosis of HeLa cells expressing and producing AexU was confirmed by 7-amino actinomycin D (7-AAD) and MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrasodium bromide] assays, by detection of cytoplasmic histone-associated DNA fragments, and by activation of caspases 3 and 9. These effects were much more pronounced in host cells that expressed and produced the full-length or NH(2)-terminal domain of AexU, compared to those that expressed and produced the COOH-terminal domain or the vector alone. This study represents the first characterization of this novel T3SS effector.

Secondary Aeromonas peritonitis is associated with polymicrobial ascites culture and absence of liver cirrhosis compared to primary Aeromonas peritonitis

Aeromonas peritonitis remains a rare condition. In this study we describe the clinical features of primary and secondary Aeromonas peritonitis, and compare the differences between these two diseases entities. Patients with Aeromonas peritonitis were identified from microbiological and medical records during the period between March 1994 and March 2003. Clinical characteristics, laboratory data, microbiological results, treatment and outcome of patients were obtained by retrospective chart review. 22 and 27 patients with primary or secondary peritonitis caused by Aeromonas species were identified. All except two of these patients were adults, with a median age of 62.4 (31-76) vs 65.8 (8-85) years, respectively. Males were predominant (82 vs 78%). Peritonitis was community acquired in 73% and 56% of patients in these two groups, respectively. Significantly higher prevalence of underlying liver cirrhosis (96 vs 7%, p<0.001), which was Child-Pugh class C in 91% of cases, in primary peritonitis was noted. Primary peritonitis was more likely to be monomicrobial (100 vs 15%, p<0.001) and complicated by bacteremia (50 vs 7%, p=0.011). A source of intraabdominal infection should be sought when Aeromonas peritonitis occurs in a patient who has no history of liver cirrhosis or who has a polymicrobial result of ascites culture.

Isolation and Characterization of Potentially Human Pathogenic, Cytotoxin-producing Aeromonas Strains from Retailed Seafood in Berlin, Germany

The presence of potentially human pathogenic strains of Aeromonas was investigated in 84 samples of seafood which were purchased from retail traders in Berlin, Germany in spring 2000. A total of 134 Aeromonas strains were isolated on selective [GSP agar and Aeromonas (Ryan) agar] and unselective (standard count agar and enterohaemolysin agar) media from 27 (32.1%) of the samples and were classified as Aeromonas hydrophila (67.9%), A. caviae (26.1%) and A. sobria (6.0%) by biotyping. Thirteen (48.1%) of the 27 positive samples contained more than one species of Aeromonas. Production of haemolysins on enterohaemolysin agar was found with 132 (98.5%) of the strains at 28 degrees C and with 130 strains (97.0%) at 37 degrees C growth temperature. Vero cytotoxins were produced by 99 (73.9%) of the strains when grown at 28 degrees C but only by 24 of the strains (17.9%) at 37 degrees C. The latter strains were identified as A. hydrophila (n = 22) and A. sobria (n = 2) which came from 17 (20.2%) samples of raw seafood and from ready-to-eat salted herring 'Matjes' products. Cytotoxin-encoding genes for aerolysin (aer) and haemolysin A (hlyA) were investigated by PCR. Aer and hlyA genes were detected in both, strains which produced toxins only at 28 degrees C and strains which produced toxins at 37 degrees C. Our data indicate that raw seafood and ready-to-eat fish products can harbour potential human pathogenic, cytotoxin producing Aeromonas strains.

Epidemiological and clinical characteristics of bacteraemia caused by Aeromonas spp. as compared with Escherichia coli and Pseudomonas aeruginosa

We reviewed 75 episodes of Aeromonas spp. bacteraemia observed at our institution in 1979-2002, with special reference to episodes occurring in elderly patients (> or = 65 y) and to nosocomial episodes. In addition, we compared monomicrobial bacteraemic episodes caused by Aeromonas spp. (n = 54) with those caused by Escherichia coli (n = 108) and Pseudomonas aeruginosa (n = 108), to assess differences in clinical presentation and outcome. The 75 episodes of Aeromonas spp. bacteraemia occurred mainly in males (72%), suffering from chronic liver disease (36%) or neoplasm (33%). They had an abdominal origin in 52% of cases, were recorded as primary bacteraemia in 40%, and showed a 30-d case fatality rate of 36%. 22 episodes (29%) were nosocomial, 36 (48%) occurred in elderly patients and 21 (28%) were polymicrobial infections. In comparison with Aeromonas spp., E. coli bacteraemia was more often associated with less severe underlying conditions, a community-acquired infection (74%), and a urinary tract (52%) or abdominal (27%) origin and had a 30-d case fatality rate of 24%. P. aeruginosa bacteraemia occurred mainly in patients with severe underlying conditions, was associated with nosocomial infection (69%), and had a 30-d case fatality rate of 43%. In conclusion, Aeromonas spp. bacteraemia is a serious infection that should be considered in patients with chronic liver disease or neoplasm. It may occur in the elderly and as a nosocomial infection, and differs in clinical findings from bacteraemia due to other common pathogens.

Evaluation of two miniaturized systems, MicroScan W/A and BBL Crystal E/NF, for identification of clinical isolates of Aeromonas spp

Fifty-two clinical strains and 22 type and reference Aeromonas strains, previously genetically characterized by 16S rRNA gene restriction fragment length polymorphism, were identified in parallel with the MicroScan Walk/Away and BBL Crystal Enteric/Nonfermenter systems. The former identified only 14.8% of the isolates correctly, and the latter identified only 20.3% correctly, which indicates that neither of these systems is useful for this purpose.