1
|
Hoffmann K, Riediger M, Tersteegen A, Marquardt P, Kahlfuß S, Kaasch AJ, Hagen RM, Frickmann H, Zautner AE. Molecular epidemiology of enterically colonizing Escherichia coli with resistance against third-generation cephalosporins isolated from stool samples of European soldiers with concomitant diarrhea on deployment in Western African Mali. Front Microbiol 2023; 14:1169829. [PMID: 37213500 PMCID: PMC10198576 DOI: 10.3389/fmicb.2023.1169829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/12/2023] [Indexed: 05/23/2023] Open
Abstract
Extended spectrum beta-lactamases (ESBL) are frequently found in Enterobacterales isolates from Western Africa. However, information on the molecular epidemiology of regional ESBL-positive Enterobacterales strains is scarce. In order to provide epidemiological information, ESBL-positive Escherichia coli isolates from stool samples of European soldiers with diarrhea deployed to a field camp in Mali were subjected to whole-genome sequencing (Illumina MiSeq and Oxford Nanopore MinION) and antimicrobial susceptibility testing. With two exemptions, sequence-based analysis suggested an absence of transmission events between soldiers as indicated by a high genetic diversity of isolates and sequence types, confirming previous rep-PCR results. Third-generation cephalosporin resistance was associated with the presence of blaCTX-M-15 genes with (n = 14) and without (n = 5) co-occurring blaTEM-1b genes. Between 0 and 6 virulence and resistance plasmids per isolate were recorded. The detected resistance plasmids could be categorized into five types, which, in turn, share different sequence-identical segments, representing particular antimicrobial resistance gene-associated mobile genetic elements (MGEs). Phenotypic resistance rates within the 19 assessed isolates that showed distinguishable colony morphologies were 94.7% (18/19) against ampicillin-sulbactam and trimethoprim/sulfamethoxazole, 68.4% (13/19) against moxifloxacin, 31.6% (6/19) against ciprofloxacin, 42.1% (8/19) against gentamicin, 31.6% (6/19) against tobramycin, and 21.1% (4/19) against piperacillin-tazobactam and fosfomycin. Virulence-associated genes mediating infectious gastroenteritis were rarely detected. The gene aggR, which is characteristic for enteroaggregative E. coli, was only detected in one single isolate. In summary, we found a variety of different strains and clonal lineages of ESBL-carrying E. coli. Transmission either between soldiers or from common contaminated sources was demonstrated in two cases and played only a minor role in this military field camp, while there were indications that resistance gene bearing MGEs had been exchanged between antimicrobial resistance gene-(ARG-)carrying plasmids.
Collapse
Affiliation(s)
- Katharina Hoffmann
- Institute of Medical Microbiology and Hospital Hygiene, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Matthias Riediger
- Institute of Medical Microbiology and Hospital Hygiene, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Aljoscha Tersteegen
- Institute of Medical Microbiology and Hospital Hygiene, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Pauline Marquardt
- Institute of Medical Microbiology and Hospital Hygiene, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Sascha Kahlfuß
- Institute of Medical Microbiology and Hospital Hygiene, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
- Institute of Molecular and Clinical Immunology, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
- Health Campus Immunology, Infectiology, and Inflammation (GCI3), Medical Center, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
- CHaMP, Center for Health and Medical Prevention, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Achim J. Kaasch
- Institute of Medical Microbiology and Hospital Hygiene, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Ralf Matthias Hagen
- Department of Microbiology and Hospital Hygiene, Bundeswehr Central Hospital Koblenz, Koblenz, Germany
| | - Hagen Frickmann
- Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Hamburg, Hamburg, Germany
- Institute for Medical Microbiology, Virology and Hospital Hygiene, University Medicine Rostock, Rostock, Germany
| | - Andreas E. Zautner
- Institute of Medical Microbiology and Hospital Hygiene, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
- CHaMP, Center for Health and Medical Prevention, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
- *Correspondence: Andreas E. Zautner,
| |
Collapse
|
2
|
Pankok F, Fuchs F, Loderstädt U, Kaase M, Balczun C, Scheithauer S, Frickmann H, Hagen RM. Molecular Epidemiology of Escherichia coli with Resistance against Third-Generation Cephalosporines Isolated from Deployed German Soldiers-A Retrospective Assessment after Deployments to the African Sahel Region and Other Sites between 2007 and 2016. Microorganisms 2022; 10:microorganisms10122448. [PMID: 36557701 PMCID: PMC9788009 DOI: 10.3390/microorganisms10122448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 12/06/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022] Open
Abstract
Colonization and infection with bacteria with acquired antibiotic resistance are among the risks for soldiers on international deployments. Enterobacterales with resistance against third-generation cephalosporines are amongst the most frequently imported microorganisms. To contribute to the scarcely available epidemiological knowledge on deployment-associated resistance migration, we assessed the molecular epidemiology of third-generation cephalosporine-resistant Escherichia coli isolated between 2007 and 2016 from German soldiers after deployments, with a particular focus on the African Sahel region. A total of 51 third-generation cephalosporine-resistant E. coli isolated from 51 military returnees from deployment collected during the assessment period between 2007 and 2016 were subjected to short-read next-generation sequencing analysis. Returnees from the Sahel region (Djibouti, Mali, South Sudan, Sudan, Sudan, and Uganda) comprised a proportion of 52.9% (27/51). Repeatedly isolated sequence types according to the Warwick University scheme from returnees from the Sahel region were ST38, ST131, and ST648, confirming previous epidemiological assessments from various sub-Saharan African regions. Locally prevalent resistance genes in isolates from returnees from the Sahel region associated with third-generation resistance were blaCTX-M-15, blaCTX-M-27, blaCTX-M-1, blaTEM-169, blaCTX-M-14, blaCTX-M-99-like, blaCTX-M-125, blaSHV-12, and blaDHA-1, while virulence genes were east1, sat, and tsh in declining order of frequency of occurrence each. In line with phenotypically observed high resistance rates for aminoglycosides and trimethoprim/sulfamethoxazole, multiple associated resistance genes were observed. A similar, slightly more diverse situation was recorded for the other deployment sites. In summary, this assessment provides first next-generation sequencing-based epidemiological data on third-generation cephalosporine-resistant E. coli imported by deployed German soldiers with a particular focus on deployments to the Sahel region, thus serving as a small sentinel. The detected sequence types are well in line with the results from previous epidemiological assessments in sub-Saharan Africa.
Collapse
Affiliation(s)
- Frederik Pankok
- Institute for Infection Control and Infectious Diseases, University Medical Center Göttingen, 37075 Göttingen, Germany
- Correspondence: (F.P.); (U.L.)
| | - Frieder Fuchs
- Department of Microbiology and Hospital Hygiene, Bundeswehr Central Hospital Koblenz, 56070 Koblenz, Germany
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Medical Faculty and University Hospital of Cologne, 50931 Cologne, Germany
| | - Ulrike Loderstädt
- Institute for Infection Control and Infectious Diseases, University Medical Center Göttingen, 37075 Göttingen, Germany
- Correspondence: (F.P.); (U.L.)
| | - Martin Kaase
- Institute for Infection Control and Infectious Diseases, University Medical Center Göttingen, 37075 Göttingen, Germany
| | - Carsten Balczun
- Department of Microbiology and Hospital Hygiene, Bundeswehr Central Hospital Koblenz, 56070 Koblenz, Germany
| | - Simone Scheithauer
- Institute for Infection Control and Infectious Diseases, University Medical Center Göttingen, 37075 Göttingen, Germany
| | - Hagen Frickmann
- Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Hamburg, 20359 Hamburg, Germany
- Institute for Medical Microbiology, Virology and Hospital Hygiene, University Medicine Rostock, 18057 Rostock, Germany
| | - Ralf Matthias Hagen
- Department of Microbiology and Hospital Hygiene, Bundeswehr Central Hospital Koblenz, 56070 Koblenz, Germany
| |
Collapse
|
3
|
Comparative Evaluation of Real-Time Screening PCR Assays for Giardia duodenalis and of Assays Discriminating the Assemblages A and B. Microorganisms 2022; 10:microorganisms10071310. [PMID: 35889028 PMCID: PMC9321168 DOI: 10.3390/microorganisms10071310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/16/2022] [Accepted: 06/27/2022] [Indexed: 11/17/2022] Open
Abstract
Due to superior sensitivity compared to traditional microscopy, real-time PCR has been well established for the diagnosis of Giardia duodenalis in human stool samples. In this study, screening real-time PCRs for different target genes of G. duodenalis, i.e., the 18S rRNA gene, the gdh (glutamate dehydrogenase) gene and the bg (beta-giardin) gene, were comparatively assessed next to various real-time PCR assays for the discrimination of the assemblages A and B of G. duodenalis targeting the bg gene with and without locked nucleic acid–containing probes as well as the tpi (triose phosphate isomerase) gene. The screening PCRs were assessed by including 872 non-preselected samples with a high pre-test probability for G. duodenalis in the statistical analysis, while 53 G. duodenalis-positive samples as indicated by at least two screening PCRs were finally included in the assessment of the assemblage-specific PCRs. For the screening PCRs, sensitivity estimated with latent class analysis (LCA) ranged from 17.5% to 100%, specificity from 92.3% to 100% with an accuracy-adjusted prevalence of 7.2% for G. duodenalis within the non-preselected sample collection. In detail, sensitivity and specificity were 100% and 100% for the 18S rRNA gene-specific assay, 17.5% and 92.3% for the gdh gene-specific assay, and 31.7% and 100% for the bg gene-specific assay, respectively. Agreement kappa was slight with only 15.5%. For the assemblage-specific PCRs, estimated sensitivity ranged from 82.1% to 100%, specificity from 84.0% to 100% with nearly perfect agreement kappa of 90.1% for assemblage A and yet substantial agreement of 74.8% for assemblage B. In detail for assemblage A, sensitivity and specificity were 100% and 100% for the bg gene-specific assay without locked nucleic acids (LNA) as well as 100% and 97.8% for both the bg gene-specific assay with LNA and the tri gene-specific assay, respectively. For assemblage B, sensitivity and specificity were 100% and 100% for the bg gene-specific assay without LNA, 96.4% and 84.0% for the bg gene-specific assay with LNA, and 82.1% and 100% for the tri gene-specific assay, respectively. Within the assessed sample collection, the observed proportion comprised 15.1% G. duodenalis assemblage A, 52.8% G. duodenalis assemblage B and 32.1% non-resolved assemblages. Only little differences were observed regarding the cycle threshold (Ct) values when comparing the assays. In conclusion, best diagnostic accuracy was shown for an 18S rRNA gene-specific screening assay for G. duodenalis and for a differentiation assay discriminating the G. duodenalis assemblages A and B by targeting the bg gene with probes not containing locked nucleic acids. By adding additional highly specific competitor assays for confirmation testing, diagnostic specificity can be further increased on the cost of sensitivity if optimized specificity is desired.
Collapse
|
4
|
Multicentric Evaluation of SeeGene Allplex Real-Time PCR Assays Targeting 28 Bacterial, Microsporidal and Parasitic Nucleic Acid Sequences in Human Stool Samples. Diagnostics (Basel) 2022; 12:diagnostics12041007. [PMID: 35454056 PMCID: PMC9032746 DOI: 10.3390/diagnostics12041007] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 04/13/2022] [Accepted: 04/15/2022] [Indexed: 12/10/2022] Open
Abstract
Prior to the implementation of new diagnostic techniques, a thorough evaluation is mandatory in order to ensure diagnostic reliability. If positive samples are scarcely available, however, such evaluations can be difficult to perform. Here, we evaluated four SeeGene Allplex real-time PCR assays amplifying a total of 28 bacteria, microsporidal and parasitic nucleic acid sequence targets in human stool samples in a multicentric approach. In the assessments with strongly positive samples, sensitivity values ranging between 13% and 100% were recorded for bacteria, between 0% and 100% for protozoa and between 7% and 100% for helminths and microsporidia; for the weakly positive samples, the recorded sensitivity values for bacteria ranged from 0% to 100%; for protozoa, from 0% to 40%; and for helminths and microsporidia, from 0% to 53%. For bacteria, the recorded specificity was in the range between 87% and 100%, while a specificity of 100% was recorded for all assessed PCRs targeting parasites and microsporidia. The intra- and inter-assay variations were generally low. Specifically for some helminth species, the sensitivity could be drastically increased by applying manual nucleic acid extraction instead of the manufacturer-recommended automatic procedure, while such effects were less obvious for the bacteria and protozoa. In summary, the testing with the chosen positive control samples showed varying degrees of discordance between the evaluated Allplex assays and the applied in-house reference assays associated with higher cycle threshold values in the Allplex assays, suggesting that samples with very low pathogen densities might be missed. As the targeted species can occur as harmless colonizers in the gut of individuals in high-endemicity settings as well, future studies should aim at assessing the clinical relevance of the latter hint.
Collapse
|
5
|
Kann S, Concha G, Hartmann M, Köller T, Alker J, Schotte U, Kreienbrock L, Frickmann H, Warnke P. Only Low Effects of Water Filters on the Enteric Carriage of Gastrointestinal Pathogen DNA in Colombian Indigenous People. Microorganisms 2022; 10:microorganisms10030658. [PMID: 35336233 PMCID: PMC8955181 DOI: 10.3390/microorganisms10030658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/28/2022] [Accepted: 03/17/2022] [Indexed: 12/18/2022] Open
Abstract
Water filtration is a common strategy of water sanitation in resource-poor tropical settings. Here, we assessed the intermediate term effect of this preventive procedure including specific filter-related as well as general hygiene training on the molecular detection of enteric pathogens in stool samples from Colombian Indigenous people. From a total of 89 individuals from an Indigenous tribe called Wiwa, stool samples were assessed by real-time PCR for enteropathogenic microorganisms prior to the implementation of water filtration-based infection prevention. Three years after the onset of the preventive strategy, a follow-up assessment was performed. A significantly beneficial effect of water filtration could be shown for Ascaris spp. only (p = 0.035) and a tendency (p = 0.059) for Hymenolepis nana. No hints for effects on the gastrointestinal shedding of Giardia duodenalis, Entamoeba histolytica, Cryptosporidium spp., Campylobacter spp., Shigella spp./enteroinvasive Escherichia coli, Necator americanus, Strongyloides stercoralis, Trichuris trichiura, and Taenia spp. were seen. In conclusion, the study indicates that water filtration can only be an element of a multi-modal hygiene concept to reduce enteric pathogen carriage in inhabitants of resource-poor tropical settings in spite of tendencies of beneficial effects.
Collapse
Affiliation(s)
- Simone Kann
- Medical Mission Institute, 97074 Würzburg, Germany
- Correspondence: (S.K.); (P.W.)
| | - Gustavo Concha
- Organization Wiwa Yugumaiun Bunkauanarrua Tayrona (OWYBT), Department Health Advocacy, Valledupar 2000001, Colombia;
| | - Maria Hartmann
- Institute for Biometry, Epidemiology and Information Processing, Veterinary Medical University Hannover, 30559 Hannover, Germany; (M.H.); (L.K.)
| | - Thomas Köller
- Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, 18057 Rostock, Germany; (T.K.); (H.F.)
| | - Juliane Alker
- Department A-Veterinary Medicine, Central Institute of the Bundeswehr Medical Service Kiel, 24119 Kronshagen, Germany; (J.A.); (U.S.)
| | - Ulrich Schotte
- Department A-Veterinary Medicine, Central Institute of the Bundeswehr Medical Service Kiel, 24119 Kronshagen, Germany; (J.A.); (U.S.)
| | - Lothar Kreienbrock
- Institute for Biometry, Epidemiology and Information Processing, Veterinary Medical University Hannover, 30559 Hannover, Germany; (M.H.); (L.K.)
| | - Hagen Frickmann
- Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, 18057 Rostock, Germany; (T.K.); (H.F.)
- Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Hamburg, 20359 Hamburg, Germany
| | - Philipp Warnke
- Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Hamburg, 20359 Hamburg, Germany
- Correspondence: (S.K.); (P.W.)
| |
Collapse
|
6
|
Tisdale MD, Tribble DR, Mitra I, Telu K, Kuo HC, Fraser JA, Liu J, Houpt ER, Riddle MS, Tilley DH, Kunz AN, Yun HC, Geist CC, Lalani T. TaqMan Array Card testing of participant-collected stool smears to determine the pathogen-specific epidemiology of travellers' diarrhoea†. J Travel Med 2022; 29:6365984. [PMID: 34494100 PMCID: PMC8763119 DOI: 10.1093/jtm/taab138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/17/2021] [Accepted: 08/19/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND We assessed the compliance with self-collection of stool smears on Whatman® FTA® Elute Card (FTA Card) and detection of travellers' diarrhoea (TD)-associated pathogens by using a quantitative Polymerase Chain Reaction (PCR) assay [customized TaqMan® array card (TAC)] in a prospective, observational cohort of travellers. METHODS Enrolled travellers documented symptoms on a travel diary and collected an FTA Card during a diarrhoeal episode, or at the end of travel if they remained asymptomatic. TAC testing was performed on FTA Cards from TD cases and 1:1 matched asymptomatic controls and 1:1 matched loose stool cases that did not meet TD criteria. Odds ratios were used to determine the association between detected pathogens and TD. RESULTS Of 2456 travellers, 484 (19.7%) completed an illness diary and met TD criteria, and 257 (53.1%) collected an FTA Card during the TD episode. FTA Cards were stored for a median of 2 years at room temperature (IQR: 1-4 years) before extraction and testing. The overall TAC detection rate in TD cases was 58.8% (95% CI: 52.5-64.8). Enterotoxigenic Escherichia coli was the most common pathogen in TD cases (26.8%), and 3.5% of samples were positive for norovirus. The odds of detecting TD-associated pathogens in 231 matched cases and asymptomatic controls were 5.4 (95% CI: 3.6-8.1) and 2.0 (95% CI: 1.1-3.7) in 121 matched TD and loose stool cases (P < 0.05). Enteroaggregative E. coli was the most common pathogen detected in asymptomatic controls and loose stool cases. Detection of diarrhoeagenic E. coli, Shigella/enteroinvasive E. coli and Campylobacter spp. was significantly associated with TD. CONCLUSION FTA Cards are a useful adjunct to traditional stool collection methods for evaluating the pathogen-specific epidemiology of TD in austere environments. Qualitative detection of pathogens was associated with TD. Measures to improve compliance and quality of FTA Card collection with decreased storage duration may further optimize detection.
Collapse
Affiliation(s)
- Michele D Tisdale
- To whom correspondence should be addressed. Infectious Disease & Travel Clinic, Building 3, 1st Floor, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Ashraf MJ, Kord M, Morovati H, Ansari S, Shekarkhar G, Badali H, Pakshir K, Shamsizadeh F, Khademi B, Shishegar M, Ahmadikia K, Zomorodian K. Evaluating a semi-nested PCR to support histopathology reports of fungal rhinosinusitis in formalin-fixed paraffin-embedded tissue samples. J Clin Lab Anal 2022; 36:e24209. [PMID: 34997792 PMCID: PMC8841172 DOI: 10.1002/jcla.24209] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/17/2021] [Accepted: 12/17/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Fungal rhinosinusitis (FRS) encompasses a various spectrum of diseases. Histopathology is the "reference method" for diagnosing FRS, but it cannot determine the genus and species. Moreover, in more than 50% of the histopathologically proven cases, the culture elicited no reliable results. This study was an attempt to evaluate the diagnostic efficiency of semi-nested polymerase chain reaction (PCR) from formalin-fixed paraffin-embedded (FFPE) functional endoscopic sinus surgery (FESS) in FRS patients. METHODS One hundred ten specimens were subjected to DNA extraction and histopathology examination. The amplification of the β-globin gene by conventional PCR was used to confirm the quality of extracted DNA. The semi-nested PCR was performed using ITS1, ITS2, and ITS4 primers during two steps. Sequencing the internal transcribed spacer region (ITS1-5.8S-ITS2) to identify causative agents was performed on PCR products. RESULTS Sixty-four out of 110 samples were positive by histopathology evidence, of which 56 samples (87.5%) were positive by PCR. Out of 46 negative samples by histopathological methods, five samples (10.9%) yielded positive results by PCR. Sensitivity, specificity, positive predictive value, and negative predictive value of the semi-nested PCR method were reported 87.5%, 89.2%, 92.7%, and 85.2%, respectively. The kappa factor between PCR and histopathological methods was 0.76, indicating substantial agreements between these two tests. CONCLUSION Due to the acceptable sensitivity and specificity of the present method, it might be used to diagnose fungal sinusitis infections along with microscopic techniques. This method is recommended to confirm the diagnose of suspected fungal sinusitis with negative histopathology results.
Collapse
Affiliation(s)
- Mohammad Javad Ashraf
- Department of Pathology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Kord
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamid Morovati
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Saham Ansari
- Department of Medical Parasitology and Mycology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Golsa Shekarkhar
- Department of Pathology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamid Badali
- Fungus Testing Laboratory, Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.,Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Kayvan Pakshir
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.,Basic Sciences in Infectious Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Forough Shamsizadeh
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Bijan Khademi
- Research Center of Otolaryngology Head and Neck Surgery, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Otolaryngology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahmood Shishegar
- Research Center of Otolaryngology Head and Neck Surgery, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Otolaryngology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Kazem Ahmadikia
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Kamiar Zomorodian
- Department of Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.,Basic Sciences in Infectious Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| |
Collapse
|
8
|
España-Cueto S, Salvador F, Oliveira I, Goterris L, Treviño B, Sánchez-Montalvá A, Serre-Delcor N, Sulleiro E, Rodríguez V, Aznar ML, Bosch-Nicolau P, Espinosa-Pereiro J, Pou D, Molina I. Epidemiological and clinical profile of adult patients with diarrhoea after international travel attended in an International Health referral center. Travel Med Infect Dis 2021; 45:102216. [PMID: 34839009 DOI: 10.1016/j.tmaid.2021.102216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 11/18/2021] [Accepted: 11/23/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The aim of the study is to describe the epidemiological, clinical, and microbiological characteristics of patients with diarrhoea after their return from a trip to tropical and subtropical areas. METHODS Retrospective study of patients with travel-related diarrhoea attended International Health referral center. Travel diarrhoea was defined as the presence of three or more liquid stools per day, or liquid stools more often than is normal for the individual, during travel or within two weeks after returning. Epidemiological, clinical and microbiological variables were collected. RESULTS 669 patients were included, 393 (58.7%) were female, with a mean age of 33 (SD 10.7) years. Abdominal pain was present in 59.6% (n = 399), and fever in 44.7% (n = 299). In 43% (n = 280) cases the etiological agent was found. Giardia duodenalis, Enteropathogenic Escherichia coli, and Enterotoxigenic Escherichia coli were the most frequent identified causative agents. Parasitic cause of the diarrhoea was associated to a longer duration of the travel, longer duration of symptoms, and having received pre-travel counseling. CONCLUSIONS In our cohort, that represents a group of travellers presenting prolonged symptoms after travel, the most frequent causes of diarrhoea were parasitic infections being the most prevalent Giardia duodenalis. This information could be relevant in order to improve travel-related diarrhoea management protocols in this type of patients.
Collapse
Affiliation(s)
- Sergio España-Cueto
- Department of Infectious Diseases, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain
| | - Fernando Salvador
- Department of Infectious Diseases, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain.
| | - Inés Oliveira
- Tropical Medicine and International Health Unit Drassanes-Vall d'Hebron, PROSICS Barcelona, Barcelona, Spain
| | - Lidia Goterris
- Department of Microbiology, Vall d'Hebron University Hospital, PROSICS Barcelona, Barcelona, Spain
| | - Begoña Treviño
- Tropical Medicine and International Health Unit Drassanes-Vall d'Hebron, PROSICS Barcelona, Barcelona, Spain
| | - Adrián Sánchez-Montalvá
- Department of Infectious Diseases, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain
| | - Núria Serre-Delcor
- Tropical Medicine and International Health Unit Drassanes-Vall d'Hebron, PROSICS Barcelona, Barcelona, Spain
| | - Elena Sulleiro
- Department of Microbiology, Vall d'Hebron University Hospital, PROSICS Barcelona, Barcelona, Spain
| | - Virginia Rodríguez
- Department of Microbiology, Vall d'Hebron University Hospital, PROSICS Barcelona, Barcelona, Spain
| | - María Luisa Aznar
- Tropical Medicine and International Health Unit Drassanes-Vall d'Hebron, PROSICS Barcelona, Barcelona, Spain
| | - Pau Bosch-Nicolau
- Department of Infectious Diseases, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain
| | - Juan Espinosa-Pereiro
- Department of Infectious Diseases, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain
| | - Diana Pou
- Tropical Medicine and International Health Unit Drassanes-Vall d'Hebron, PROSICS Barcelona, Barcelona, Spain
| | - Israel Molina
- Department of Infectious Diseases, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, PROSICS Barcelona, Barcelona, Spain
| |
Collapse
|
9
|
Comparison of Three Real-Time PCR Assays Targeting the SSU rRNA Gene, the COWP Gene and the DnaJ-Like Protein Gene for the Diagnosis of Cryptosporidium spp. in Stool Samples. Pathogens 2021; 10:pathogens10091131. [PMID: 34578163 PMCID: PMC8472038 DOI: 10.3390/pathogens10091131] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 08/29/2021] [Accepted: 09/02/2021] [Indexed: 02/07/2023] Open
Abstract
As qualified microscopy of enteric parasitoses as defined by high diagnostic accuracy is difficult to maintain in non-endemic areas due to scarce opportunities for practicing with positive sample materials, molecular diagnostic options provide less investigator-dependent alternatives. Here, we compared three molecular targets for the real-time PCR-based detection of Cryptosporidium spp. From a population of 1000 individuals comprising both Ghanaian HIV (human immunodeficiency virus) patients and military returnees after deployment in the tropics, stool samples were assessed for Cryptosporidium spp. by real-time PCR targeting the small subunit ribosomal RNA (SSU rRNA) gene, the Cryptosporidium oocyst wall (COWP) gene, and the DnaJ-like protein gene (DnaJ), respectively. In declining order, sensitivity of 100% for the SSU rRNA gene PCR, 90.0% for the COWP PCR and 88.8% for the DnaJ PCR, respectively, as well as specificity of 99.6% for the COWP PCR and 96.9% for both the SSU rRNA gene PCR and the DnaJ PCR, respectively, were recorded. Substantial agreement (kappa value 0.663) between the three assays was observed. Further, an accuracy-adjusted Cryptosporidium spp. prevalence of 6.0% was calculated for the study population. In conclusion, none of the assessed real-time PCR assays were associated with perfect test accuracy. However, a combination of highly sensitive SSU rRNA gene PCR for screening purposes and more specific COWP PCR for confirmatory testing should allow reliable diagnosis of Cryptosporidium spp. in stool samples even in low prevalence settings.
Collapse
|
10
|
Loderstädt U, Frickmann H. Antimicrobial resistance of the enteric protozoon Giardia duodenalis - A narrative review. Eur J Microbiol Immunol (Bp) 2021; 11:29-43. [PMID: 34237023 PMCID: PMC8287975 DOI: 10.1556/1886.2021.00009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 06/17/2021] [Indexed: 12/15/2022] Open
Abstract
Introduction As therapy-refractory giardiasis is an emerging health issue, this review aimed at summarizing mechanisms of reduced antimicrobial susceptibility in Giardia duodenalis and strategies to overcome this problem. Methods A narrative review on antimicrobial resistance in G. duodenalis was based upon a selective literature research. Results Failed therapeutic success has been observed for all standard therapies of giardiasis comprising nitroimidazoles like metronidazole or tinidazole as first line substances but also benznidazoles like albendazole and mebendazole, the nitrofuran furazolidone, the thiazolide nitazoxanide, and the aminoglycoside paromomycin. Multicausality of the resistance phenotypes has been described, with differentiated gene expression due to epigenetic and post-translational modifications playing a considerable bigger role than mutational base exchanges in the parasite DNA. Standardized resistance testing algorithms are not available and clinical evidence for salvage therapies is scarce in spite of research efforts targeting new giardicidal drugs. Conclusion In case of therapeutic failure of first line nitroimidazoles, salvage strategies including various options for combination therapy exist in spite of limited evidence and lacking routine diagnostic-compatible assays for antimicrobial susceptibility testing in G. duodenalis. Sufficiently powered clinical and diagnostic studies are needed to overcome both the lacking evidence regarding salvage therapy and the diagnostic neglect of antimicrobial resistance.
Collapse
Affiliation(s)
- Ulrike Loderstädt
- 1Institute for Infection Control and Infectious Diseases, University Medical Center Göttingen, 37075 Göttingen, Germany
| | - Hagen Frickmann
- 2Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Hamburg, 20359 Hamburg, Germany.,3Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, 18057 Rostock, Germany
| |
Collapse
|
11
|
Loderstädt U, Hagen RM, Hahn A, Frickmann H. New Developments in PCR-Based Diagnostics for Bacterial Pathogens Causing Gastrointestinal Infections-A Narrative Mini-Review on Challenges in the Tropics. Trop Med Infect Dis 2021; 6:tropicalmed6020096. [PMID: 34199650 PMCID: PMC8293448 DOI: 10.3390/tropicalmed6020096] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 05/31/2021] [Accepted: 05/31/2021] [Indexed: 12/15/2022] Open
Abstract
The application of modern PCR approaches for the diagnosis of bacterial gastrointestinal pathogens is on the rise due to their rapidly available results combined with high sensitivity. While multiple studies describe the ongoing implementation of this technique for routine diagnostic purposes in laboratories in Western industrialized countries, reports on successful and also sustainable respective approaches in resource-poor tropical settings are still scarce. In order to shed light on potential reasons for this marked discrepancy, this narrative review summarizes identified challenges for the application of diagnostic PCR targeting bacterial gastrointestinal pathogens from stool samples in the tropics. The identified and discussed issues comprise the lack of generally accepted definitions for (1) minimum standards regarding sample acquisition, storage and transport time for diagnostic PCR analyses in the tropics, (2) nucleic acid extraction standards allowing an optimum detection of all types of pathogens which may be responsible for gastroenteritis in the tropics, (3) validation standards to ensure comparable quality of applied diagnostic assays, and (4) cut-offs for a reliable discrimination of infection and mere colonization in areas where semi-immunity due to repeated exposition associated with poor hygiene conditions has to be expected. Further implementation research is needed to solve those issues.
Collapse
Affiliation(s)
- Ulrike Loderstädt
- Institute for Infection Control and Infectious Diseases, University Medical Center Göttingen, 37075 Göttingen, Germany;
| | - Ralf Matthias Hagen
- Department of Microbiology and Hospital Hygiene, Bundeswehr Central Hospital Koblenz, Andernacher Str. 100, 56070 Koblenz, Germany;
| | - Andreas Hahn
- Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, 18057 Rostock, Germany;
| | - Hagen Frickmann
- Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, 18057 Rostock, Germany;
- Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Hamburg, 20359 Hamburg, Germany
- Correspondence: or or ; Tel.: +49-40-6947-28743
| |
Collapse
|
12
|
Schotte U, Hoffmann T, Schwarz NG, Rojak S, Lusingu J, Minja D, Kaseka J, Mbwana J, Gesase S, May J, Dekker D, Frickmann H. Study of enteric pathogens among children in the tropics and effects of prolonged storage of stool samples. Lett Appl Microbiol 2021; 72:774-782. [PMID: 33544912 DOI: 10.1111/lam.13457] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 01/13/2021] [Accepted: 01/28/2021] [Indexed: 12/11/2022]
Abstract
The study was performed to compare real-time PCR after nucleic acid extraction directly from stool samples as well as from samples stored and transported on Whatman papers or flocked swabs at ambient temperature in the tropics. In addition, the possible suitability for a clear determination of likely aetiological relevance of PCR-based pathogen detections based on cycle threshold (Ct) values was assessed. From 632 Tanzanian children <5 years of age with and without gastrointestinal symptoms, 466 samples were subjected to nucleic acid extraction and real-time PCR for gastrointestinal viral, bacterial and protozoan pathogens. Equal or even higher frequencies of pathogen detections from Whatman papers or flocked swabs were achieved compared with nucleic acid extraction directly from stool samples. Comparison of the Ct values showed no significant difference according to the nucleic acid extraction strategy. Also, the Ct values did not allow a decision whether a detected pathogen was associated with gastrointestinal symptoms.
Collapse
Affiliation(s)
- U Schotte
- Department A - Veterinary Medicine, Central Institute of the Bundeswehr Medical Service Kiel, Kronshagen, Germany
| | - T Hoffmann
- Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Hamburg, Hamburg, Germany
| | - N G Schwarz
- Infectious Disease Epidemiology Department, Bernhard Nocht Institute for Tropical Medicine Hamburg, Hamburg, Germany
| | - S Rojak
- Department of Microbiology and Hospital Hygiene, Bundeswehr Central Hospital Koblenz, Koblenz, Germany
| | - J Lusingu
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | - D Minja
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | - J Kaseka
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | - J Mbwana
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | - S Gesase
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | - J May
- Infectious Disease Epidemiology Department, Bernhard Nocht Institute for Tropical Medicine Hamburg, Hamburg, Germany
| | - D Dekker
- Infectious Disease Epidemiology Department, Bernhard Nocht Institute for Tropical Medicine Hamburg, Hamburg, Germany
| | - H Frickmann
- Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Hamburg, Hamburg, Germany.,Department of Medical Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany
| |
Collapse
|
13
|
Bacterial, viral and parasitic pathogens analysed by qPCR: Findings from a prospective study of travellers' diarrhoea. Travel Med Infect Dis 2020; 40:101957. [PMID: 33359433 DOI: 10.1016/j.tmaid.2020.101957] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 12/19/2020] [Accepted: 12/21/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The diagnostics of travellers' diarrhoea (TD) has been revolutionised by multiplex qPCR assays. While mostly of bacterial aetiology, viruses and parasites account for the disease among 10-20% of travellers. Despite this, prospective studies applying qPCR assays remain scarce that cover not only bacteria, such as the various diarrhoeagenic Escherichia coli (DEC), but also viral and parasitic pathogens. METHOD We analysed by qPCR pre- and post-travel stool samples of 146 Finnish travellers for bacterial, viral and parasitic pathogens: enteropathogenic (EPEC), enteroaggregative (EAEC), enterotoxigenic (ETEC), enterohaemorrhagic (EHEC), and enteroinvasive (EIEC) E. coli; Shigella, Campylobacter, Salmonella, Yersinia and Vibrio cholerae; norovirus G1 and G2, rotavirus, enteroviruses, and sapovirus; and Giardia lamblia, Entamoeba histolytica, and Cryptosporidium. Symptoms and medication data during travel were collected by questionnaires. RESULTS We detected bacterial pathogens in 102/146 samples (69.9%; EAEC, EPEC, ETEC most common), viral ones in 13 (8.9%; norovirus most common), and parasitic ones in one (0.7%; Giardia). Noroviruses were associated with severe symptoms (23.5% versus non-severe 4.9%). In the TD group, 41.7% (5/12) of those with viral pathogens (vs. 13.3%; 11/83 without) took antibiotics. CONCLUSION Viral pathogens, particularly noroviruses, prevail in severe TD. The symptoms of viral disease are often severe and lead to unwarranted use of antibiotics.
Collapse
|
14
|
Tanida K, Hahn A, Frickmann H. Comparison of two commercial and one in-house real-time PCR assays for the diagnosis of bacterial gastroenteritis. Eur J Microbiol Immunol (Bp) 2020; 10:210-216. [PMID: 33279885 PMCID: PMC7753976 DOI: 10.1556/1886.2020.00030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 11/18/2020] [Indexed: 12/14/2022] Open
Abstract
Introduction The aim of the study was a comparative evaluation of in-house real-time PCR and commercial real-time PCR (Fast Track Diagnostics (FTD), ampliCube/Mikrogen) targeting enteropathogenic bacteria from stool in preparation of Regulation (EU) 2017/746 on in vitro diagnostic medical devices. Methods Both 241 stool samples from patients and 100 samples from German laboratory control schemes (“Ringversuche”) were used to comparatively assess in-house real-time PCR, the FTD bacterial gastroenteritis kit, and the ampliCube gastrointestinal bacterial panels 1&2 either with the in-house PCRs as gold standard and as a test comparison without gold standard applying latent class analysis. Sensitivity, specificity, intra- and inter-assay variation and Cohen’s kappa were assessed. Results In comparison with the gold standard, sensitivity was 75–100% for strongly positive samples, 20–100% for weakly positive samples, and specificity ranged from 96 to 100%. Latent class analysis suggested that sensitivity ranges from 81.2 to 100% and specificity from 58.5 to 100%. Cohen’s kappa varied between moderate and nearly perfect agreement, intra- and inter-assay variation was 1–3 to 1–4 Ct values. Conclusion Acceptable agreement and performance characteristics suggested replaceability of the in-house PCR assays by the commercial approaches.
Collapse
Affiliation(s)
- Konstantin Tanida
- 1Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Hamburg, Hamburg, Germany
| | - Andreas Hahn
- 2Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany
| | - Hagen Frickmann
- 1Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Hamburg, Hamburg, Germany.,2Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany
| |
Collapse
|
15
|
Halfter M, Müseler U, Hagen RM, Frickmann H. Enteric pathogens in German police officers after predominantly tropical deployments - A retrospective assessment over 5 years. Eur J Microbiol Immunol (Bp) 2020; 10:172-177. [PMID: 33021951 PMCID: PMC7592512 DOI: 10.1556/1886.2020.00026] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 09/04/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction The study was performed to assess the infection risk of German police officers on predominantly tropical deployments, mostly United Nations missions, with gastrointestinal pathogens. Methods Police officers were offered PCR-based screening for gastrointestinal pathogens before and after deployment. The screening panel comprised enteroinvasive bacteria (Salmonella spp., Shigella spp./enteroinvasive Escherichia coli, Campylobacter jejuni, and Yersinia spp.), enteropathogenic protozoa (Entamoeba histolytica, Giardia duodenalis, Cryptosporidium spp., and Cyclospora cayetanensis), as well as enteric helminths (Ancyclostoma spp., Ascaris lumbricoides, Enterobius vermicularis, Hymenolepis nana, Necator americanus, African Schistosoma spp., Strongyloides stercoralis, Taenia saginata, Taenia solium, and Trichuris trichiura). Results G. duodenalis (n = 3), C. jejuni (n = 2), Salmonella spp. (n = 1), Shigella spp./enteroinvasive E. coli (n = 3), and S. stercoralis (n = 3) were detect in 12 out of 133 (9.0%) police officers. The majority had shown gastrointestinal symptoms on deployment and all were asymptomatic at the time of medical assessment. The major infection sites were Sub-Saharan Africa followed by Northern Africa and the Middle East. Conclusions Deployment of police officers to tropical deployment sites on United Nations missions is associated with a considerable acquisition risk of gastrointestinal pathogens in a quantitatively relevant minority. Post-deployment screening is advisable to facilitate therapeutic and hygiene-related consequences.
Collapse
Affiliation(s)
- Matthias Halfter
- 1Department of Tropical Medicine and Infectious Diseases, Bundeswehr Hospital Hamburg, Hamburg, Germany
| | | | - Ralf Matthias Hagen
- 3Department of Microbiology and Hospital Hygiene, Bundeswehr Central Hospital Koblenz, Koblenz, Germany
| | - Hagen Frickmann
- 4Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Hamburg, Hamburg, Germany.,5Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany
| |
Collapse
|
16
|
Wiemer D, Schwarz NG, Burchard GD, Frickmann H, Loderstaedt U, Hagen RM. Surveillance of enteropathogenic bacteria, protozoa and helminths in travellers returning from the tropics. Eur J Microbiol Immunol (Bp) 2020; 10:147-155. [PMID: 32910786 PMCID: PMC7592519 DOI: 10.1556/1886.2020.00015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/11/2020] [Indexed: 11/19/2022] Open
Abstract
Diarrhoea is a frequent symptom associated with travelling to tropical regions, but the cause is often not found. Epidemiology was assessed including up-to-date real-time PCR approaches.We analysed datasets of 528 patients who presented at the Bernhard Nocht Institute for Tropical Medicine in Hamburg, Germany, between 2006 and 2010 for screening purposes or because of diarrhoea. Stool samples were obtained and investigated by microscopy, bacterial culture, two PCR assays targeting Entamoeba histolytica, Entamoeba dispar, Giardia duodenalis, and Cryptosporidium parvum, or Salmonella spp., Shigella/EIEC spp., Campylobacter jejuni, and Yersinia spp.Among patients with gastrointestinal symptoms, 51% tested positive for bacteria or parasites, of which 66% had a known enteropathogenic potential. In patients without diarrhoea, 53% (n = 80) were positive, and 33% of these cases harboured agents of pathogenic potential. Association with clinical symptoms was primarily found for bacterial infections. Blastocystis hominis, however, was more frequent in asymptomatic than in symptomatic travellers.In conclusion, the study stresses the etiological relevance of bacterial gastroenteritis in travellers returning from the tropics, the need for molecular approaches to increase diagnostic sensitivity and demonstrates that asymptomatic carriage of enteropathogens after prolonged stays in the tropics is similarly frequent compared with symptomatic infections in travellers.
Collapse
Affiliation(s)
- Dorothea Wiemer
- 1Department of Tropical Medicine at the Bernhard Nocht Institute, Bundeswehr Hospital Hamburg, Hamburg, Germany
| | | | | | - Hagen Frickmann
- 1Department of Tropical Medicine at the Bernhard Nocht Institute, Bundeswehr Hospital Hamburg, Hamburg, Germany.,3Institute for Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany
| | | | - Ralf-Matthias Hagen
- 4Department for Microbiology and Hospital Hygiene, Bundeswehr Central Hospital Koblenz, Koblenz, Germany
| |
Collapse
|
17
|
Köller T, Hahn A, Altangerel E, Verweij JJ, Landt O, Kann S, Dekker D, May J, Loderstädt U, Podbielski A, Frickmann H. Comparison of commercial and in-house real-time PCR platforms for 15 parasites and microsporidia in human stool samples without a gold standard. Acta Trop 2020; 207:105516. [PMID: 32371221 DOI: 10.1016/j.actatropica.2020.105516] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/20/2020] [Accepted: 04/20/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION A test comparison of in-house and commercial real-time PCR (qPCR) kits for the detection of human parasites and microsporidia in stool samples was conducted without a gold standard. Three different commercial kits were included in the comparison, with a range of 3-15 different PCR targets, while 14 targets were covered by in-house testing, so not all 16 target pathogens were covered by all assays. METHODS Residual materials from nucleic acid extractions of stool samples with very high likelihood of being colonized or infected by at least one enteric parasite species or microsporidia were tested. In all, 500 DNA samples were analyzed, but due to limited sample volume, only 250 of the 500 samples were tested per assay. Each sample was assessed with the qPCR platforms being compared and cycle threshold (Ct) values were included in a descriptive comparison. RESULTS Depending on the assay applied, qPCR detected per 250 tested samples Giardia duodenalis (184-205), Blastocystis spp. (174-183), Trichuris trichiura (118-120), Ascaris lumbricoides (79-96), Necator americanus (78-106), Hymenolepis nana (40-42), Cryptosporidium spp. (27-36), Dientamoeba fragilis (26-28), Schistosoma spp. (13-23), Enterobius vermicularis (8-14), Entamoeba histolytica (7-16), Strongyloides stercoralis (6-38), Cyclospora spp. (6-13), Taenia spp. (1-4), microsporidia (1-5), and Ancylostoma spp. (1-2). Inter-assay agreement kappa was almost perfect (0.81-1) for Dientamoeba fragilis, Hymenolepis nana, Cryptosporidium spp., and Ascaris lumbricoides, substantial (0.61-0.8) for Necator americanus, Blastocystis spp., Ancylostoma spp., Giardia duodenalis, Schistosoma spp., Trichuris trichiura, and Enterobius vermicularis, moderate (0.41-0.6) for Entamoeba histolytica, fair (0.21-0.4) for microsporidia, slight (0-0.2) for Cyclospora spp. and Strongyloides stercoralis, and poor (<0) for Taenia spp. CONCLUSIONS Varying inter-assay agreement makes interpretation of microsporidia and parasite PCR in stool samples challenging. Intra-assay agreement had been controlled during the developing of the assays. Future studies, e.g., with optimized nucleic acid procedures and including microscopically characterized samples, are advisable.
Collapse
|
18
|
Olson S, Hall A, Riddle MS, Porter CK. Travelers' diarrhea: update on the incidence, etiology and risk in military and similar populations - 1990-2005 versus 2005-2015, does a decade make a difference? Trop Dis Travel Med Vaccines 2019; 5:1. [PMID: 30675367 PMCID: PMC6332902 DOI: 10.1186/s40794-018-0077-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 12/20/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Travelers' diarrhea remains a prevalent illness impacting individuals visiting developing countries, however most studies have focused on this disease in the context of short term travel. This study aims to determine the regional estimates of travelers' diarrhea incidence, pathogen-specific prevalence, and describe the morbidity associated with diarrheal disease among deployed military personnel and similar long term travelers. METHODS We updated a prior systematic review to include publications between January 1990 and June 2015. Point estimates and confidence intervals of travelers' diarrhea and pathogen prevalence were combined in a random effects model and assessed for heterogeneity. Eighty-two studies were included in the analysis, including 29 new studies since the prior systematic review. RESULTS Military personnel were evaluated in 69% of studies and non-military long term travelers in 34%, with a median duration of travel of 4.9 months, and travel predominantly to the Middle East, Southeast Asia, and Latin America and the Caribbean. Sixty-two percent of tested cases were due to bacterial pathogens, with enterotoxigenic E. coli (ETEC), enteroaggregative E. coli (EAEC), and Campylobacter predominating, and significant regional variability. The incidence of TD from studies with longitudinal data was 36.3 cases per 100 person-months, with the highest rates in Southeast Asia, Latin America and the Caribbean, and the Middle East, with higher estimates from those studies using self-reporting of disease. Morbidity remained significant, with 21% being incapacitated or placed sick in quarters (SIQ) by their illness, 15% requiring intravenous fluids, and 3% requiring hospitalization. CONCLUSIONS In comparison to results from the prior systematic review, there were no significant differences in incidence, pathogen prevalence, or morbidity; however there was a trend toward improved care-seeking by sick individuals.
Collapse
Affiliation(s)
- Scott Olson
- Enteric Disease Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
| | - Alexis Hall
- Enteric Disease Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
| | - Mark S. Riddle
- Uniformed Services University of the Health Sciences, Bethesda, MD USA
| | - Chad K. Porter
- Enteric Disease Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
| |
Collapse
|
19
|
Lääveri T, Vlot JA, van Dam AP, Häkkinen HK, Sonder GJB, Visser LG, Kantele A. Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) among travellers to Africa: destination-specific data pooled from three European prospective studies. BMC Infect Dis 2018; 18:341. [PMID: 30037325 PMCID: PMC6057027 DOI: 10.1186/s12879-018-3245-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 07/09/2018] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND One third of travellers to low- and middle-income regions of the tropics and subtropics become colonized by extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE). The risk varies by destination and, for each traveller, may be substantially further increased by travellers' diarrhoea (TD) and antibiotic use. Despite the risk of TD in Africa, ESBL-PE acquisition rates in all studies are lower there than in Asia. Africa has become increasingly popular as a destination for international travellers, yet minimal data are available from the continent's subregions and countries. METHODS We analysed subregion- and country-specific data on carriage and risk factors for ESBL-PE colonization pooled from three prospective studies conducted between 2009 and 2013 among Finnish and Dutch travellers. The data were subjected to multivariable analysis of risk factors. In addition, we compared our data to two recent large investigations reporting data by subregion and country. RESULTS Our joint analysis comprised data on 396 travellers. The ESBL-PE colonization rate was highest in Northern Africa, followed by Middle and Eastern Africa, and lowest in Southern and Western Africa. Of individual countries with more than 15 visitors, the highest rates were seen for Egypt (12/17; 70.6%), Ghana (6/23; 26.1%), and Tanzania (14/81; 17.3%); the rates among travellers to Egypt were comparable to those reported in South and Southeast Asia. In a pooled multivariable analysis, travel destination, age, overnight hospitalisation abroad, TD, and use of fluoroquinolones were independently associated with increased ESBL-PE colonization rates. CONLUSIONS Even in areas with relatively low risk of colonization, antimicrobials clearly predispose to colonization with ESBL-PE. Travellers to Africa should be cautioned against unnecessary use of antibiotics.
Collapse
Affiliation(s)
- Tinja Lääveri
- Inflammation Center, Division of Infectious Diseases, University of Helsinki and Helsinki University Hospital, POB 348, FIN-00029 HUS,, Helsinki, Finland
| | - Jessica A Vlot
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Alje P van Dam
- Department of Infectious Diseases, Public Health Service (GGD), Amsterdam, The Netherlands.,Department of Internal Medicine, Division of Infectious Diseases, Tropical Medicine and AIDS, Academic Medical Centre, Amsterdam, The Netherlands
| | | | - Gerard J B Sonder
- Department of Infectious Diseases, Public Health Service (GGD), Amsterdam, The Netherlands.,Department of Internal Medicine, Division of Infectious Diseases, Tropical Medicine and AIDS, Academic Medical Centre, Amsterdam, The Netherlands
| | - Leo G Visser
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Anu Kantele
- Inflammation Center, Division of Infectious Diseases, University of Helsinki and Helsinki University Hospital, POB 348, FIN-00029 HUS,, Helsinki, Finland. .,Clinicum, University of Helsinki, Helsinki, Finland. .,Aava Travel Clinic, Medical Centre Aava, Helsinki, Finland. .,Unit of Infectious Diseases, Karolinska Institutet, Solna, Stockholm, Sweden.
| |
Collapse
|
20
|
Resistant Gram-Negative Bacteria and Diagnostic Point-of-Care Options for the Field Setting during Military Operations. BIOMED RESEARCH INTERNATIONAL 2018; 2018:9395420. [PMID: 30009178 PMCID: PMC6020508 DOI: 10.1155/2018/9395420] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 05/07/2018] [Accepted: 05/20/2018] [Indexed: 12/16/2022]
Abstract
The spread of multidrug-resistant bacteria in resource-poor settings affects the military medical service in case of deployments of soldiers to war and crisis zones. Patients with war injuries are prone to colonization or infection with multidrug-resistant bacteria. Resistant Gram-negative bacteria play a dominant role in military wound infections. Problematic hygiene conditions on deployment facilitate exposition of soldiers with subsequent colonization. Although colonizing strains are frequently cleared from their hosts after returning from deployment, transmission to close contacts of the soldiers in the home country cannot be excluded and therapeutic options are reduced if colonization progresses to invasive infection. Since sophisticated culture-based diagnostic approaches are typically not available in the field setting on deployment, molecular rapid diagnostic test systems are an option for transmission control if the locally prevalent molecular resistance mechanisms are known. Efforts for global resistance surveillance can contribute to better understanding of resistance distribution and spread at deployment sites. This review summarizes experience of the military medical services with multidrug resistance on deployment and with the influx of resistant strains to the home country and discusses potential use of available molecular rapid test systems as an option for the field setting.
Collapse
|
21
|
Frickmann H, Hagen RM, Geiselbrechtinger F, Hoysal N. Infectious diseases during the European Union training mission Mali (EUTM MLI) - a four-year experience. Mil Med Res 2018; 5:19. [PMID: 29848381 PMCID: PMC5977544 DOI: 10.1186/s40779-018-0166-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 05/15/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The European Union Training Mission Mali (EUTM MLI) is a multinational military training deployment to the Western African tropical nation of Mali. Based on routinely collected disease and non-battle injury surveillance data, this study quantifies the true impact of infectious diseases for this tropical mission and potential seasonal variations in infectious disease threats. METHODS Categorized health events during the EUTM MLI mission and associated lost working days were reported using the EpiNATO-2 report. Infection-related health events were descriptively analyzed for a 4-year period from the 12th week in 2013 to the 13th week in 2017. Aggregated EpiNATO-2 data collected from all missions other than EUTM MLI were used as a comparator. RESULTS Among the infectious diseases reported by EUTM MLI, non-severe upper respiratory infections and gastrointestinal diseases dominated quantitatively, accounting for 1.65 and 1.42 consultations per 100 person-weeks, respectively. The number of recorded infectious disease-associated lost working days during the whole study interval was 723. Seasonal changes in disease frequency were detectable. More gastrointestinal infections were seen in the rainy season, and more respiratory infections occurred in the dry season; these were associated with peaks of more than 2.5 consultations per 100 person-weeks for both categories. CONCLUSIONS Despite initial concerns focused on tropical infectious diseases during this mission in tropical Mali, upper respiratory tract and gastrointestinal infections predominate. The relatively low number of reported lost working days may indicate that these infections are at the milder end of the spectrum of infectious diseases despite a likely reporting bias.
Collapse
Affiliation(s)
- Hagen Frickmann
- Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Hamburg, Bernhard Nocht Str. 74, 20359, Hamburg, Germany. .,Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, Schillingallee 70, 18057, Rostock, Germany.
| | - Ralf Matthias Hagen
- Department of Preventive Medicine, Bundeswehr Medical Academy, Neuherbergstraße 11, 80937, Munich, Germany
| | - Florian Geiselbrechtinger
- NATO Center of Excellence for Military Medicine (MilMedCOE), Deployment Health Surveillance Capability (DHSC), Dachauer Str. 128, 80637, Munich, Germany.,Institute of Medical Information Processing, Biometry and Epidemiology, LMU Munich, Marchionini-Str. 15, 81377, Munich, Germany
| | - Nagpal Hoysal
- NATO Center of Excellence for Military Medicine (MilMedCOE), Deployment Health Surveillance Capability (DHSC), Dachauer Str. 128, 80637, Munich, Germany
| |
Collapse
|
22
|
Lääveri T, Pakkanen SH, Kirveskari J, Kantele A. Travellers' diarrhoea: Impact of TD definition and control group design on study results. Travel Med Infect Dis 2018; 24:37-43. [PMID: 29409749 DOI: 10.1016/j.tmaid.2018.01.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 01/24/2018] [Accepted: 01/25/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Travellers' diarrhoea (TD) is a common health problem among visitors to the (sub)tropics. Much research deals with aetiology, prevention, and post-infection sequalae, yet the data may not allow comparisons due to incompatible definitions of TD and No TD control groups. METHOD The impact of defining TD and No TD control groups was explored by revisiting our recent data. We set up two TD groups: classical TD i.e. ≥3 loose or liquid stools/day and WHO TD (diarrhoea as defined by the WHO) i.e. any diarrhoea, and four No TD groups by TD definition and timing (no classical/WHO TD during travel, no ongoing classical/WHO TD). RESULTS TD was recorded for 37% versus 65% of subjects when using classical versus WHO definitions, respectively; the proportions of the various pathogens proved similar. The strictest criterion for the No TD control group (no WHO TD during travel) yielded pathogens among 61% and the least strict (no ongoing classical TD) among 73% of the travellers; the differences were greatest for enteroaggregative Escherichia coli and Campylobacter. CONCLUSIONS Definition of TD and control group design substantially impact on TD study results. The WHO definition yields more cases, but the pathogen selection is similar by both definitions. Design of the No TD control group was found critical: only those remaining asymptomatic throughout the journey should be included.
Collapse
Affiliation(s)
- Tinja Lääveri
- Inflammation Center, Division of Infectious Diseases, University of Helsinki and Helsinki University Hospital, POB 348, FIN-00029 HUS, Helsinki, Finland
| | - Sari H Pakkanen
- Department of Bacteriology and Immunology, University of Helsinki, P.O. Box 21, FIN-00014 Helsinki, Finland
| | - Juha Kirveskari
- Helsinki University Hospital Laboratory (HUSLAB), Department of Bacteriology, POB 720, FIN-00029 HUS, Helsinki, Finland; Mobidiag Ltd, Keilaranta 16 A, FIN-02150 Espoo, Finland
| | - Anu Kantele
- Inflammation Center, Division of Infectious Diseases, University of Helsinki and Helsinki University Hospital, POB 348, FIN-00029 HUS, Helsinki, Finland; Clinicum, University of Helsinki, PO Box 63, FIN-00014, Helsinki, Finland; Aava Travel Clinic, Medical Centre Aava, Annankatu 32, FIN-00100 Helsinki, Finland; Unit of Infectious Diseases, Department of Medicine/Solna, Karolinska Institutet, SE-17176 Stockholm, Sweden.
| |
Collapse
|
23
|
Lääveri T, Vilkman K, Pakkanen SH, Kirveskari J, Kantele A. A prospective study of travellers' diarrhoea: analysis of pathogen findings by destination in various (sub)tropical regions. Clin Microbiol Infect 2017; 24:908.e9-908.e16. [PMID: 29133155 DOI: 10.1016/j.cmi.2017.10.034] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 09/12/2017] [Accepted: 10/24/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Eighty million travellers visiting (sub)tropical regions contract travellers' diarrhoea (TD) each year, yet prospective data comparing the prevalence of TD pathogens in various geographical regions are scarce. Our recent study using modern molecular methods found enteropathogenic (EPEC) and enteroaggregative (EAEC) Escherichia coli to be the most frequent pathogens, followed by enterotoxigenic E. coli (ETEC) and Campylobacter. We revisited our data to compare the findings by geographical region. METHODS A total of 459 prospectively recruited travellers provided stool samples and completed questionnaires before and after visiting destinations in various geographical regions. A multiplex quantitative real-time PCR assay was used to analyse Salmonella, Yersinia, Campylobacter jejuni/Campylobacter coli, Shigella, Vibrio cholerae, EPEC, EAEC, ETEC, enterohaemorrhagic E. coli and enteroinvasive E. coli. RESULTS TD was contracted by 69% (316/459) of the subjects; EPEC and EAEC outnumbered ETEC and Campylobacter in all regions. Multiple pathogens were detected in 42% (133/316) of the samples. The proportions of all pathogens varied by region. The greatest differences were seen for Campylobacter: while relatively frequent in South Asia (n = 11; 20% of the 55 with TD during travel) and Southeast Asia (15/84, 15%), it was less common in East and West Africa (5/71, 7% and 1/57, 2%) and absent in South America and the Caribbean (0/40). CONCLUSIONS EPEC and EAEC outnumbered ETEC and Campylobacter everywhere, yet the proportions of pathogen findings varied by region, with ETEC and Campylobacter rates showing the greatest differences. The high frequency of multibacterial findings in many regions indicates a need for further investigation of the clinical role of each pathogen.
Collapse
Affiliation(s)
- T Lääveri
- Inflammation Center, Division of Infectious Diseases, Helsinki University Hospital, Finland and University of Helsinki, Finland
| | - K Vilkman
- Inflammation Center, Division of Infectious Diseases, Helsinki University Hospital, Finland and University of Helsinki, Finland; Aava Travel Clinic, Medical Centre Aava, Helsinki, Finland
| | - S H Pakkanen
- Department of Bacteriology and Immunology, University of Helsinki, Finland
| | - J Kirveskari
- Department of Bacteriology, Helsinki University Hospital Laboratory (HUSLAB), Finland
| | - A Kantele
- Inflammation Center, Division of Infectious Diseases, Helsinki University Hospital, Finland and University of Helsinki, Finland; Aava Travel Clinic, Medical Centre Aava, Helsinki, Finland; Clinicum, University of Helsinki, Finland; Unit of Infectious Diseases, Department of Medicine/Solna, Karolinska Institutet, Stockholm, Sweden.
| |
Collapse
|
24
|
Hahn A, Luetgehetmann M, Landt O, Schwarz NG, Frickmann H. Comparison of one commercial and two in-house TaqMan multiplex real-time PCR assays for detection of enteropathogenic, enterotoxigenic and enteroaggregative Escherichia coli. Trop Med Int Health 2017; 22:1371-1376. [PMID: 28906580 DOI: 10.1111/tmi.12976] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Enteropathogenic, enterotoxigenic and enteroaggregative Escherichia coli (EPEC, ETEC, EAEC) are among the most frequent causes of diarrhoea during travel or on military deployments. Cost-efficient and reliable real-time multiplex PCR (mPCR) assays are desirable for surveillance or point prevalence studies in remote and resource-limited tropical settings. We compared one commercial PCR kit and two in-house assays without using a gold standard to estimate sensitivity and specificity of each assay. METHODS Residual materials from nucleic acid extractions of stool samples from two groups with presumably different prevalences and increased likelihood of being infected or colonised by diarrhoeagenic E. coli were included in the assessment. One group comprised samples from returnees from tropical deployments, the second group was of migrants and study participants from high-endemicity settings. Each sample was assessed with all of the PCR assays. Cycle threshold (Ct) values were descriptively compared. RESULTS The calculated sensitivities for the commercial test vs. the in-house tests were for EPEC 0.84 vs. 0.89 and 0.96, for ETEC 0.83 vs. 0.76 and 0.61, and for EAEC 0.69 vs. 0.54 and 0.69. False positive results were rare - specificity was 0.94 and 0.97 for two EPEC tests and 1.0 for all other tests. Most positive samples had late Ct values corresponding to low quantities of pathogens. Discordant test results were associated with late Ct values. CONCLUSIONS As commercial and in-house assays showed comparable results, in-house tests can be assumed to be safe while affording considerable savings, making them a valuable alternative for surveillance testing in resource-limited tropical areas.
Collapse
Affiliation(s)
- Andreas Hahn
- Institute for Microbiology, Charité-University Medicine Berlin, Berlin, Germany
| | - Marc Luetgehetmann
- Institute for Medical Microbiology, Virology and Hygiene, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | - Norbert Georg Schwarz
- Infectious Disease Epidemiology, Bernhard Nocht Institute for Tropical Medicine Hamburg, Hamburg, Germany
| | - Hagen Frickmann
- Department of Tropical Medicine at the Bernhard Nocht Institute, Bundeswehr Hospital Hamburg, Hamburg, Germany.,Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany
| |
Collapse
|
25
|
Zautner AE, Groß U, Emele MF, Hagen RM, Frickmann H. More Pathogenicity or Just More Pathogens?-On the Interpretation Problem of Multiple Pathogen Detections with Diagnostic Multiplex Assays. Front Microbiol 2017; 8:1210. [PMID: 28706515 PMCID: PMC5489565 DOI: 10.3389/fmicb.2017.01210] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 06/14/2017] [Indexed: 12/15/2022] Open
Abstract
Modern molecular diagnostic approaches in the diagnostic microbiological laboratory like real-time quantitative polymerase chain reaction (qPCR) have led to a considerable increase of diagnostic sensitivity. They usually outperform the diagnostic sensitivity of culture-based approaches. Culture-based diagnostics were found to be insufficiently sensitive for the assessment of the composition of biofilms in chronic wounds and poorly standardized for screenings for enteric colonization with multi-drug resistant bacteria. However, the increased sensitivity of qPCR causes interpretative challenges regarding the attribution of etiological relevance to individual pathogen species in case of multiple detections of facultative pathogenic microorganisms in primarily non-sterile sample materials. This is particularly the case in high-endemicity settings, where continuous exposition to respective microorganisms leads to immunological adaptation and semi-resistance while considerable disease would result in case of exposition of a non-adapted population. While biofilms in chronic wounds show higher pathogenic potential in case of multi-species composition, detection of multiple pathogens in respiratory samples is much more difficult to interpret and asymptomatic enteric colonization with facultative pathogenic microorganisms is frequently observed in high endemicity settings. For respiratory samples and stool samples, cycle-threshold-value-based semi-quantitative interpretation of qPCR results has been suggested. Etiological relevance is assumed if cycle-threshold values are low, suggesting high pathogen loads. Although the procedure is challenged by lacking standardization and methodical issues, first evaluations have led to promising results. Future studies should aim at generally acceptable quantitative cut-off values to allow discrimination of asymptomatic colonization from clinically relevant infection.
Collapse
Affiliation(s)
- Andreas E. Zautner
- Institut für Medizinische Mikrobiologie, Universitätsmedizin GöttingenGöttingen, Germany
| | - Uwe Groß
- Institut für Medizinische Mikrobiologie, Universitätsmedizin GöttingenGöttingen, Germany
| | - Matthias F. Emele
- Institut für Medizinische Mikrobiologie, Universitätsmedizin GöttingenGöttingen, Germany
| | - Ralf M. Hagen
- Abteilung A Lehre Gesundheitsversorgung, Sanitätsakademie der BundeswehrMünchen, Germany
| | - Hagen Frickmann
- Fachbereich Tropenmedizin am Bernhard-Nocht Institut, Bundeswehrkrankenhaus HamburgHamburg, Germany
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsmedizin RostockRostock, Germany
| |
Collapse
|
26
|
Müller M, Lehmann P, Willy C. [Antibiotic stewardship : A programmatic approach to improved antimicrobial management]. Unfallchirurg 2017; 120:540-548. [PMID: 28608289 DOI: 10.1007/s00113-017-0365-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Due to the increasing selection and prevalence of multidrug-resistant gram-negative bacteria and the insufficient development of novel antibiotics, the responsible and prudent use of the available antimicrobial drugs is of major importance. In Germany the rational use of anti-infectives considering the local antimicrobial resistance situation is defined in the infection protection act of 2011. An important tool to follow legal regulations and to improve the treatment of bacterial infections is the antimicrobial stewardship (AMS) concept. Hospitals implementing an AMS program charge a multidisciplinary team of experts to develop and monitor treatment standards and to establish a system of regular consultations and ward rounds. Objectives of this set of measures are the optimization of the individual treatment outcome and on a longer range the improvement of the epidemiological situation. AMS programs include all clinical disciplines that use antimicrobials. Trauma surgery is also affected in a special way as soon as complicated infections and those with multidrug-resistant bacteria are treated.
Collapse
Affiliation(s)
- Martin Müller
- Abteilung I Mikrobiologie, Zentrales Institut des Sanitätsdienstes der Bundeswehr Kiel/Berlin, Scharnhorststraße 14, 10115, Berlin, Deutschland.
| | - Patrick Lehmann
- Apotheke, Bundeswehrkrankenhaus Berlin, Scharnhorststraße 13, 10115, Berlin, Deutschland
| | - Christian Willy
- Abteilung Unfallchirurgie und Orthopädie, Septische und Rekonstruktive Chirurgie, Forschungs- und Behandlungszentrum Septische Defektwunden, Bundeswehrkrankenhaus Berlin, Scharnhorststraße 13, 10115, Berlin, Deutschland
| |
Collapse
|
27
|
Münch J, Hagen RM, Müller M, Kellert V, Wiemer DF, Hinz R, Schwarz NG, Frickmann H. Colonization with Multidrug-Resistant Bacteria - On the Efficiency of Local Decolonization Procedures. Eur J Microbiol Immunol (Bp) 2017; 7:99-111. [PMID: 28690877 PMCID: PMC5495082 DOI: 10.1556/1886.2017.00008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 04/27/2017] [Indexed: 01/16/2023] Open
Abstract
The effectiveness of a disinfectant-based decolonization strategy for multidrug-resistant bacteria like extended spectrum β-lactamase (ESBL)-positive Gram-negative bacteria with or without additional fluoroquinolon and carbapenem resistance as well as vancomycin-resistant enterococci and methicillin-resistant Staphylococcus aureus was assessed. Between 2011 and 2015, 25 patients from Libya, Syria, and the Ukraine with war traumata were treated at the Bundeswehr hospital Hamburg. The patients were heavily colonized and infected with multidrug-resistant bacteria, altogether comprising 371 distinct combinations of pathogens and isolation sites. Local disinfection was assessed for effectiveness regarding successful decolonization of multidrug-resistant bacteria. Altogether, 170 cases of successful decolonization were observed, comprising 95 (55.8%) such events at sampling sites that were accessible to disinfecting procedures. The remaining 75 (44.2%) decolonization events had to be considered as spontaneous. In contrast, 95 out of 172 (55.2%) colonized isolation sites that were accessible to disinfection procedures were successfully decolonized. Patient compliance with the enforced hygiene procedures was associated with decolonization success. Systemic antibiotic therapy did not relevantly affect isolation time. Disinfecting washing moderately supports local decolonization of multidrug-resistant pathogens in comparison with spontaneous decolonization rates if the patients’ compliance with the applied hygiene procedures is ensured.
Collapse
Affiliation(s)
- Julia Münch
- Department of Internal Medicine, Bundeswehr Hospital Hamburg, Hamburg, Germany
| | - Ralf Matthias Hagen
- Department of Preventive Medicine, Bundeswehr Medical Academy, Munich, Germany
| | - Martin Müller
- Central Institute of the Bundeswehr Medical Service Kiel, Department Berlin, Berlin, Germany
| | - Viktor Kellert
- Department of Hygiene, Bundeswehr Hospital Hamburg, Hamburg, Germany
| | - Dorothea Franziska Wiemer
- Department of Tropical Medicine at the Bernhard Nocht Institute, Bundeswehr Hospital Hamburg, Hamburg, Germany
| | - Rebecca Hinz
- Institute for Medical Microbiology, Virology and Hygiene, Bundeswehr Hospital Hamburg, Hamburg, Germany
| | - Norbert Georg Schwarz
- Infectious Disease Epidemology, Bernhard Nocht Institute for Tropical Medicine Hamburg, Hamburg, Germany
| | - Hagen Frickmann
- Department of Tropical Medicine at the Bernhard Nocht Institute, Bundeswehr Hospital Hamburg, Hamburg, Germany.,Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany
| |
Collapse
|
28
|
Maaßen W, Wiemer D, Frey C, Kreuzberg C, Tannich E, Hinz R, Wille A, Fritsch A, Hagen RM, Frickmann H. Microbiological screenings for infection control in unaccompanied minor refugees: the German Armed Forces Medical Service's experience. Mil Med Res 2017; 4:13. [PMID: 28451440 PMCID: PMC5402321 DOI: 10.1186/s40779-017-0123-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 04/19/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The German Military Medical Service contributed to the medical screening of unaccompanied minor refugees (UMRs) coming to Germany in 2014 and 2015. In this study, a broad range of diagnostic procedures was applied to identify microorganisms with clinical or public health significance. Previously, those tests had only been used to screen soldiers returning from tropical deployments. This instance is the first time the approach has been studied in a humanitarian context. METHODS The offered screenings included blood cell counts, hepatitis B serology and microscopy of the stool to look for protozoa and worm eggs as well as PCR from stool samples targeting pathogenic bacteria, protozoa and helminths. If individuals refused certain assessments, their decision to do so was accepted. A total of 219 apparently healthy male UMRs coming from Afghanistan, Egypt, Somalia, Eritrea, Syria, Ghana, Guinea, Iran, Algeria, Iraq, Benin, Gambia, Libya, Morocco, Pakistan, and Palestine were assessed. All UMRs who were examined at the study department were included in the assessment. RESULTS We detected decreasing frequencies of pathogens that included diarrhoea-associated bacteria [Campylobacter (C.) jejuni, enteropathogenic Escherichia (E.) coli (EPEC), enterotoxic E. coli (ETEC), enteroaggregative E. coli (EAEC), enteroinvasive E. coli (EIEC)/Shigella spp.), Giardia (G.) duodenalis, helminths (comprising Schistosoma spp., Hymenolepis (H.) nana, Strongyloides (S.) stercoralis] as well as hepatitis B virus. Pathogenic microorganisms dominated the samples by far. While G. duodenalis was detected in 11.4% of the assessed UMRs, the incidence of newly identified cases in the German population was 4.5 cases per 100,000 inhabitants. CONCLUSIONS We conclude that the applied in-house PCR screening systems, which have proven to be useful for screening military returnees from tropical deployments, can also be used for health assessment of immigrants from the respective sites. Apparently healthy UMRs may be enterically colonized with a broad variety of pathogenic and apathogenic microorganisms. Increased colonization rates, as shown for G. duodenalis, can pose a hygiene problem in centralized homes for asylum seekers.
Collapse
Affiliation(s)
- Winfried Maaßen
- Department of Tropical Medicine at the Bernhard Nocht Institute, German Armed Forces Hospital of Hamburg, Bernhard Nocht Street 74, D-20359 Hamburg, Germany
| | - Dorothea Wiemer
- Department of Tropical Medicine at the Bernhard Nocht Institute, German Armed Forces Hospital of Hamburg, Bernhard Nocht Street 74, D-20359 Hamburg, Germany
| | - Claudia Frey
- Department of Tropical Medicine at the Bernhard Nocht Institute, German Armed Forces Hospital of Hamburg, Bernhard Nocht Street 74, D-20359 Hamburg, Germany
| | - Christina Kreuzberg
- Department of Tropical Medicine at the Bernhard Nocht Institute, German Armed Forces Hospital of Hamburg, Bernhard Nocht Street 74, D-20359 Hamburg, Germany
- German Society for International Cooperation (GIZ), Bonn, Germany
| | - Egbert Tannich
- Department of Molecular Parasitology, Bernhard Nocht Institute for Tropical Medicine Hamburg, Hamburg, Germany
| | - Rebecca Hinz
- Department of Tropical Medicine at the Bernhard Nocht Institute, German Armed Forces Hospital of Hamburg, Bernhard Nocht Street 74, D-20359 Hamburg, Germany
- Institute of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Wille
- Institute for Hygiene and Environment, Hamburg, Germany
| | - Andreas Fritsch
- Department of Laboratory Medicine, German Armed Forces Hospital of Hamburg, Hamburg, Germany
| | - Ralf Matthias Hagen
- NATO Center of Excellence for Military Medicine (MilMedCOE), Deployment Health Surveillance Capability (DHSC), Munich, Germany
| | - Hagen Frickmann
- Department of Tropical Medicine at the Bernhard Nocht Institute, German Armed Forces Hospital of Hamburg, Bernhard Nocht Street 74, D-20359 Hamburg, Germany
- Institute for Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany
| |
Collapse
|
29
|
Squire SA, Ryan U. Cryptosporidium and Giardia in Africa: current and future challenges. Parasit Vectors 2017; 10:195. [PMID: 28427454 PMCID: PMC5397716 DOI: 10.1186/s13071-017-2111-y] [Citation(s) in RCA: 165] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 03/24/2017] [Indexed: 12/15/2022] Open
Abstract
Cryptosporidium and Giardia are important causes of diarrhoeal illness. Adequate knowledge of the molecular diversity and geographical distribution of these parasites and the environmental and climatic variables that influence their prevalence is important for effective control of infection in at-risk populations, yet relatively little is known about the epidemiology of these parasites in Africa. Cryptosporidium is associated with moderate to severe diarrhoea and increased mortality in African countries and both parasites negatively affect child growth and development. Malnutrition and HIV status are also important contributors to the prevalence of Cryptosporidium and Giardia in African countries. Molecular typing of both parasites in humans, domestic animals and wildlife to date indicates a complex picture of both anthroponotic, zoonotic and spill-back transmission cycles that requires further investigation. For Cryptosporidium, the only available drug (nitazoxanide) is ineffective in HIV and malnourished individuals and therefore more effective drugs are a high priority. Several classes of drugs with good efficacy exist for Giardia, but dosing regimens are suboptimal and emerging resistance threatens clinical utility. Climate change and population growth are also predicted to increase both malnutrition and the prevalence of these parasites in water sources. Dedicated and co-ordinated commitments from African governments involving "One Health" initiatives with multidisciplinary teams of veterinarians, medical workers, relevant government authorities, and public health specialists working together are essential to control and prevent the burden of disease caused by these parasites.
Collapse
Affiliation(s)
- Sylvia Afriyie Squire
- School of Veterinary and Life Sciences, Murdoch University, Perth, Australia
- Council for Scientific and Industrial Research, Animal Research Institute, Accra, Ghana
| | - Una Ryan
- School of Veterinary and Life Sciences, Murdoch University, Perth, Australia
| |
Collapse
|
30
|
Frickmann H, Wiemer D, Frey C, Hagen RM, Hinz R, Podbielski A, Köller T, Warnke P. Low Enteric Colonization with Multidrug-Resistant Pathogens in Soldiers Returning from Deployments- Experience from the Years 2007-2015. PLoS One 2016; 11:e0162129. [PMID: 27598775 PMCID: PMC5012679 DOI: 10.1371/journal.pone.0162129] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 08/17/2016] [Indexed: 11/24/2022] Open
Abstract
This assessment describes the enteric colonization of German soldiers 8–12 weeks after returning from mostly but not exclusively subtropical or tropical deployment sites with third-generation cephalosporin-resistant Enterobacteriaceae, vancomycin-resistant enterococci (VRE), and methicillin-resistant Staphylococcus aureus (MRSA). Between 2007 and 2015, 828 stool samples from returning soldiers were enriched in nonselective broth and incubated on selective agars for Enterobacteriaceae expressing extended-spectrum beta-lactamases (ESBL), VRE and MRSA. Identification and resistance testing of suspicious colonies was performed using MALDI-TOF-MS, VITEK-II and agar diffusion gradient testing (bioMérieux, Marcy-l’Étoile, France). Isolates with suspicion of ESBL were characterized by ESBL/ampC disc-(ABCD)-testing and molecular approaches (PCR, Sanger sequencing). Among the returnees, E. coli with resistance against third-generation cephalosporins (37 ESBL, 1 ESBL + ampC, 1 uncertain mechanism) were found in 39 instances (4.7%). Associated quinolone resistance was found in 46.2% of these isolates. Beta-lactamases of the blaCTX-M group 1 predominated among the ESBL mechanisms, followed by the blaCTX-M group 9, and blaSHV. VRE of vanA-type was isolated from one returnee (0.12%). MRSA was not isolated at all. There was no clear trend regarding the distribution of resistant isolates during the assessment period. Compared with colonization with resistant bacteria described in civilians returning from the tropics, the colonization in returned soldiers is surprisingly low and stable. This finding, together with high colonization rates found in previous screenings on deployment, suggests a loss of colonization during the 8- to 12-week period between returning from the deployments and assessment.
Collapse
Affiliation(s)
- Hagen Frickmann
- Department of Tropical Medicine at the Bernhard Nocht Institute, German Armed Forces Hospital of Hamburg, Hamburg, Germany
- Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany
- * E-mail:
| | - Dorothea Wiemer
- Department of Tropical Medicine at the Bernhard Nocht Institute, German Armed Forces Hospital of Hamburg, Hamburg, Germany
| | - Claudia Frey
- Department of Tropical Medicine at the Bernhard Nocht Institute, German Armed Forces Hospital of Hamburg, Hamburg, Germany
| | - Ralf Matthias Hagen
- Deployment Health Surveillance Capability, NATO Center of Excellence for Military Medicine, Munich, Germany
| | - Rebecca Hinz
- Department of Tropical Medicine at the Bernhard Nocht Institute, German Armed Forces Hospital of Hamburg, Hamburg, Germany
| | - Andreas Podbielski
- Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany
| | - Thomas Köller
- Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany
| | - Philipp Warnke
- Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany
| |
Collapse
|
31
|
Hagen RM, Hinz R, Frickmann H. β-Lactamases Encoded by blaCTX-M Group I Genes as Determinants of Resistance of Esbl-Positive Enterobacteriaceae in European Soldiers in Tropical Mali. Eur J Microbiol Immunol (Bp) 2015; 5:281-4. [PMID: 26716016 PMCID: PMC4681355 DOI: 10.1556/1886.2015.00037] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 10/03/2015] [Indexed: 11/21/2022] Open
Abstract
ESBL (extended-spectrum-β-lactamase)-positive Enterobacteriaceae, which colonized European soldiers in tropical Western African Mali, were subjected to a molecular assessment of their resistance determinants. By doing so, a better insight into the locally endemic pattern of ESBL-associated β-lactamase genes was aspired. From a previous study on diarrhea in European soldiers on deployment in tropical Mali, 15 ESBL-positive Escherichia coli with demonstrated high clonal diversity and one positive Klebsiella pneumoniae were assessed. Polymerase chain reactions (PCRs) for blaTEM and blaSHV β-lactamase genes with subsequent sequencing for the discrimination of ESBL- and non-ESBL variants were performed, followed by four group-specific PCRs for blaCTX-M genes. Non-ESBL-associated blaTEM-1 was identified in six out of 15 (40%) E. coli strains, while 100% of the assessed strains were positive for group I blaCTX-M. Considering the known clonal diversity of the assessed strains, the striking restriction to one group of blaCTX-M genes accounting for the ESBL phenotypes of the isolates suggests little genetic exchange in the local setting. Under such circumstances of restricted numbers of locally endemic target genes, PCR-based screening approaches for ESBL colonization might be promising.
Collapse
Affiliation(s)
- Ralf Matthias Hagen
- Department of Tropical Medicine at the Bernhard Nocht Institute, German Armed Forces Hospital of Hamburg , Germany
| | - Rebecca Hinz
- Department of Tropical Medicine at the Bernhard Nocht Institute, German Armed Forces Hospital of Hamburg , Germany
| | - Hagen Frickmann
- Department of Tropical Medicine at the Bernhard Nocht Institute, German Armed Forces Hospital of Hamburg , Germany ; Institute for Microbiology and Immunology, University Medicine Rostock , Germany
| |
Collapse
|