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Golparian D, Cole MJ, Sánchez-Busó L, Day M, Jacobsson S, Uthayakumaran T, Abad R, Bercot B, Caugant DA, Heuer D, Jansen K, Pleininger S, Stefanelli P, Aanensen DM, Bluemel B, Unemo M. Antimicrobial-resistant Neisseria gonorrhoeae in Europe in 2020 compared with in 2013 and 2018: a retrospective genomic surveillance study. Lancet Microbe 2024; 5:e478-e488. [PMID: 38614111 DOI: 10.1016/s2666-5247(23)00370-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 08/20/2023] [Accepted: 11/09/2023] [Indexed: 04/15/2024]
Abstract
BACKGROUND Regular quality-assured whole-genome sequencing linked to antimicrobial resistance (AMR) and patient metadata is imperative to elucidate the shifting gonorrhoea epidemiology, both nationally and internationally. We aimed to examine the gonococcal population in the European Economic Area (EEA) in 2020, elucidate emerging and disappearing gonococcal lineages associated with AMR and patient metadata, compare with 2013 and 2018 whole-genome sequencing data, and explain changes in gonococcal AMR and gonorrhoea epidemiology. METHODS In this retrospective genomic surveillance study, we analysed consecutive gonococcal isolates that were collected in EEA countries through the European Gonococcal Antimicrobial Surveillance Programme (Euro-GASP) in 2020, and made comparisons with Euro-GASP data from 2013 and 2018. All isolates had linked AMR data (based on minimum inhibitory concentration determination) and patient metadata. We performed whole-genome sequencing and molecular typing and AMR determinants were derived from quality-checked whole-genome sequencing data. Links between genomic lineages, AMR, and patient metadata were examined. FINDINGS 1932 gonococcal isolates collected in 2020 in 21 EEA countries were included. The majority (81·2%, 147 of 181 isolates) of azithromycin resistance (present in 9·4%, 181 of 1932) was explained by the continued expansion of the Neisseria gonorrhoeae sequence typing for antimicrobial resistance (NG-STAR) clonal complexes (CCs) 63, 168, and 213 (with mtrD/mtrR promoter mosaic 2) and the novel NG-STAR CC1031 (semi-mosaic mtrD variant 13), associated with men who have sex with men and anorectal or oropharyngeal infections. The declining cefixime resistance (0·5%, nine of 1932) and negligible ceftriaxone resistance (0·1%, one of 1932) was largely because of the progressive disappearance of NG-STAR CC90 (with mosaic penA allele), which was predominant in 2013. No known resistance determinants for novel antimicrobials (zoliflodacin, gepotidacin, and lefamulin) were found. INTERPRETATION Azithromycin-resistant clones, mainly with mtrD mosaic or semi-mosaic variants, appear to be stabilising at a relatively high level in the EEA. This mostly low-level azithromycin resistance might threaten the recommended ceftriaxone-azithromycin therapy, but the negligible ceftriaxone resistance is encouraging. The decreased genomic population diversity and increased clonality could be explained in part by the COVID-19 pandemic resulting in lower importation of novel strains into Europe. FUNDING European Centre for Disease Prevention and Control and Örebro University Hospital.
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Affiliation(s)
- Daniel Golparian
- WHO Collaborating Centre for Gonorrhoea and Other Sexually Transmitted Infections, Department of Laboratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | | | - Leonor Sánchez-Busó
- Genomics and Health Area, Foundation for the Promotion of Health and Biomedical Research in the Valencian Community (FISABIO-Public Health), Valencia, Spain; CIBERESP, ISCIII, Madrid, Spain
| | | | - Susanne Jacobsson
- WHO Collaborating Centre for Gonorrhoea and Other Sexually Transmitted Infections, Department of Laboratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | | | - Raquel Abad
- Reference Laboratory for Neisseria, National Centre of Microbiology-Instituto de Salud Carlos III, Majadahonda, Spain
| | - Beatrice Bercot
- French National Reference Center for Bacterial STI, Associated Laboratory for Gonococci, APHP, Paris Cité University, IAME 1137, Paris, France
| | | | - Dagmar Heuer
- Unit 18: 'Sexually Transmitted Bacterial Pathogens and HIV', Department of Infectious Disease, Robert Koch Institute, Berlin, Germany
| | - Klaus Jansen
- Unit 34: 'HIV/AIDS, STI and Blood-Borne Infections', Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | | | - Paola Stefanelli
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - David M Aanensen
- Centre for Genomic Pathogen Surveillance, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Benjamin Bluemel
- European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and Other Sexually Transmitted Infections, Department of Laboratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Institute for Global Health, University College London, London, UK.
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Smith P, Le Devendec L, Jouy E, Larvor E, Lesne J, Kirschner AKT, Rehm C, Leopold M, Pleininger S, Heger F, Jäckel C, Göllner C, Nekat J, Hammerl JA, Baron S. Epidemiological cut-off values for non-O1/ non-O139 Vibrio cholerae disc diffusion data generated by standardised methods. Dis Aquat Organ 2023; 156:115-121. [PMID: 38095366 DOI: 10.3354/dao03766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
This work generates the data needed to set epidemiological cut-off values for disc-diffusion zone measurements of Vibrio cholerae. The susceptibility of 147 European isolates of non-O1/non-O139 V. cholerae to 19 antibiotics was established using a standardised disc diffusion method which specified incubation of Mueller Hinton agar plates at 35°C. Epidemiological cut-off values were calculated by analysis of the zone size data with the statistically based normalised resistance interpretation method. Cut-off values for 17 agents were calculated by analysis of the aggregated data from all 4 laboratories participating in this study. The cut-off values calculated were ≥18 mm for amoxicillin/clavulanate, ≥18 mm for amikacin, ≥19 mm for ampicillin, ≥27 mm for cefepime, ≥31 mm for cefotaxime, ≥24 mm for ceftazidime, ≥24 mm for chloramphenicol, ≥31 mm for ciprofloxacin, ≥16 mm for erythromycin, ≥ 27 mm for florfenicol, ≥16 mm for gentamicin, ≥23 mm for imipenem, ≥25 mm for meropenem, ≥29 mm for nalidixic acid, ≥28 mm for norfloxacin, ≥13 mm for streptomycin and ≥23 mm for tetracycline. For the other 2 agents the data from 1 laboratory was excluded from the censored aggregation because the data from that laboratory was considered excessively imprecise. The cut-off values for these 2 agents calculated for the aggregation of the data from 3 laboratories were ≥23 mm for trimethoprim and ≥24 mm for trimethoprim/sulfamethoxazole. These zone size data will be submitted to the Clinical Laboratory Standards Institute (CLSI) and European Committee for Antimicrobial Susceptibility Testing (EUCAST) for their consideration in setting international consensus epidemiological cut-off values for non O1/non-O139 V. cholerae.
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Affiliation(s)
- Peter Smith
- School of Natural Science, University of Galway, Galway H91 TK33, Ireland
| | - Laëtitia Le Devendec
- Anses, Ploufragan-Plouzané-Niort Laboratory, Mycoplasmology-Bacteriology and Antimicrobial Resistance Unit, 22440 Ploufragan, France
| | - Eric Jouy
- Anses, Ploufragan-Plouzané-Niort Laboratory, Mycoplasmology-Bacteriology and Antimicrobial Resistance Unit, 22440 Ploufragan, France
| | - Emeline Larvor
- Anses, Ploufragan-Plouzané-Niort Laboratory, Mycoplasmology-Bacteriology and Antimicrobial Resistance Unit, 22440 Ploufragan, France
| | - Jean Lesne
- École des Hautes Études en Sante Publique, Laboratoire d'Étude et de Recherche en Environnent et Sante, 35000 Rennes, France
| | - Alexander K T Kirschner
- Institute for Hygiene and Applied Immunology - Water Microbiology, Medical University Vienna, Kinderspitalgasse 15, 1090 Austria
- Division Water Quality & Health, Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500 Krems, Austria
- Interuniversity Cooperation Centre Water & Health, www.waterandhealth.at
| | - Carmen Rehm
- Institute for Hygiene and Applied Immunology - Water Microbiology, Medical University Vienna, Kinderspitalgasse 15, 1090 Austria
- Division Water Quality & Health, Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500 Krems, Austria
- Interuniversity Cooperation Centre Water & Health, www.waterandhealth.at
| | - Melanie Leopold
- Division Water Quality & Health, Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500 Krems, Austria
- Interuniversity Cooperation Centre Water & Health, www.waterandhealth.at
| | - Sonja Pleininger
- Institute for Medical Microbiology and Hygiene, Austrian Agency for Health and Food Safety, Austria, Waehringer Strasse 25A, 1094 Vienna, Austria
| | - Florian Heger
- Institute for Medical Microbiology and Hygiene, Austrian Agency for Health and Food Safety, Austria, Waehringer Strasse 25A, 1094 Vienna, Austria
| | - Claudia Jäckel
- Consultant Laboratory for Vibrio spp. in Food, Department Biological Safety, German Federal Institute for Risk Assessment, Max-Dohrn Str. 8-10, 1089 Berlin, Germany
| | - Cornelia Göllner
- Consultant Laboratory for Vibrio spp. in Food, Department Biological Safety, German Federal Institute for Risk Assessment, Max-Dohrn Str. 8-10, 1089 Berlin, Germany
| | - Jonas Nekat
- Consultant Laboratory for Vibrio spp. in Food, Department Biological Safety, German Federal Institute for Risk Assessment, Max-Dohrn Str. 8-10, 1089 Berlin, Germany
| | - Jens Andre Hammerl
- Consultant Laboratory for Vibrio spp. in Food, Department Biological Safety, German Federal Institute for Risk Assessment, Max-Dohrn Str. 8-10, 1089 Berlin, Germany
| | - Sandrine Baron
- Anses, Ploufragan-Plouzané-Niort Laboratory, Mycoplasmology-Bacteriology and Antimicrobial Resistance Unit, 22440 Ploufragan, France
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3
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Rehm C, Kolm C, Pleininger S, Heger F, Indra A, Reischer GH, Farnleitner AAH, Kirschner AKT. Vibrio cholerae-An emerging pathogen in Austrian bathing waters? Wien Klin Wochenschr 2023; 135:597-608. [PMID: 37530997 PMCID: PMC10651712 DOI: 10.1007/s00508-023-02241-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 06/11/2023] [Indexed: 08/03/2023]
Abstract
Vibrio cholerae, an important human pathogen, is naturally occurring in specific aquatic ecosystems. With very few exceptions, only the cholera-toxigenic strains belonging to the serogroups O1 and O139 are responsible for severe cholera outbreaks with epidemic or pandemic potential. All other nontoxigenic, non-O1/non-O139 V. cholerae (NTVC) strains may cause various other diseases, such as mild to severe infections of the ears, of the gastrointestinal and urinary tracts as well as wound and bloodstream infections. Older, immunocompromised people and patients with specific preconditions have an elevated risk. In recent years, worldwide reports demonstrated that NTVC infections are on the rise, caused amongst others by elevated water temperatures due to global warming.The aim of this review is to summarize the knowledge gained during the past two decades on V. cholerae infections and its occurrence in bathing waters in Austria, with a special focus on the lake Neusiedler See. We investigated whether NTVC infections have increased and which specific environmental conditions favor the occurrence of NTVC. We present an overview of state of the art methods that are currently available for clinical and environmental diagnostics. A preliminary public health risk assessment concerning NTVC infections related to the Neusiedler See was established. In order to raise awareness of healthcare professionals for NTVC infections, typical symptoms, possible treatment options and the antibiotic resistance status of Austrian NTVC isolates are discussed.
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Affiliation(s)
- Carmen Rehm
- Division Water Quality and Health, Karl-Landsteiner University of Health Sciences, Krems, Austria
- Institute for Hygiene and Applied Immunology - Water Microbiology, Medical University Vienna, Vienna, Austria
- Interuniversity Cooperation Centre Water & Health
| | - Claudia Kolm
- Division Water Quality and Health, Karl-Landsteiner University of Health Sciences, Krems, Austria
- Interuniversity Cooperation Centre Water & Health
- Institute for Chemical, Environmental and Bioscience Engineering, Research Group Microbiology and Molecular Diagnostics 166/5/3, Technische Universität Wien, Vienna, Austria
| | - Sonja Pleininger
- Institute for Medical Microbiology and Hygiene, National Reference Centre for Vibrio cholerae, Austrian Agency for Health and Food Safety (AGES), Vienna, Austria
| | - Florian Heger
- Institute for Medical Microbiology and Hygiene, National Reference Centre for Vibrio cholerae, Austrian Agency for Health and Food Safety (AGES), Vienna, Austria
| | - Alexander Indra
- Institute for Medical Microbiology and Hygiene, National Reference Centre for Vibrio cholerae, Austrian Agency for Health and Food Safety (AGES), Vienna, Austria
- Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Georg H Reischer
- Interuniversity Cooperation Centre Water & Health
- Institute for Chemical, Environmental and Bioscience Engineering, Research Group Microbiology and Molecular Diagnostics 166/5/3, Technische Universität Wien, Vienna, Austria
| | - Andreas A H Farnleitner
- Division Water Quality and Health, Karl-Landsteiner University of Health Sciences, Krems, Austria
- Interuniversity Cooperation Centre Water & Health
- Institute for Chemical, Environmental and Bioscience Engineering, Research Group Microbiology and Molecular Diagnostics 166/5/3, Technische Universität Wien, Vienna, Austria
| | - Alexander K T Kirschner
- Division Water Quality and Health, Karl-Landsteiner University of Health Sciences, Krems, Austria.
- Institute for Hygiene and Applied Immunology - Water Microbiology, Medical University Vienna, Vienna, Austria.
- Interuniversity Cooperation Centre Water & Health, .
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Heger F, Schindler S, Pleininger S, Fueszl A, Blaschitz M, Lippert K, Hyden P, Hufnagl P, Mutschlechner D, Gremmel T, Hofer E, Markowicz M, Indra A. Three Cases of Tickborne Francisella tularensis Infection, Austria, 2022. Emerg Infect Dis 2023; 29:2349-2352. [PMID: 37877608 PMCID: PMC10617340 DOI: 10.3201/eid2911.230460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023] Open
Abstract
Tularemia is increasing in Austria. We report Francisella tularensis subspecies holarctica isolated from 3 patients who had been bitten by arthropods. Next-generation sequencing showed substantial isolate similarity. Clinicians should consider bloodstream F. tularensis infections for patients with signs/symptoms of ulceroglandular tularemia, and surveillance of potential vectors should be intensified.
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Traugott MT, Pleininger S, Inschlag-Tisch S, Eder B, Seitz T, Merrelaar A, Reiß-Kornfehl J, Fussi J, Schindler S, Blaschitz M, Heger F, Indra A, Karolyi M, Staudacher M, Oelschlaegel T, Hoepler W, Neuhold S, Wenisch C. Correction: A case of fulminant respiratory diphtheria in a 24-year-old Afghan refugee in Austria in May 2022: a case report. Infection 2023; 51:497-498. [PMID: 36639594 PMCID: PMC10042953 DOI: 10.1007/s15010-022-01964-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- M T Traugott
- IV Medical Department with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Kundratstraße 3, 1100, Vienna, Austria.
| | - S Pleininger
- Austrian Reference Centre for Diphtheria, Austrian Agency for Health and Food Safety, Vienna, Austria
| | - S Inschlag-Tisch
- Department of Internal Medicine, Cardiology and Nephrology, Hospital of Wiener Neustadt, Wiener Neustadt, Austria
| | - B Eder
- IV Medical Department with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Kundratstraße 3, 1100, Vienna, Austria
| | - T Seitz
- IV Medical Department with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Kundratstraße 3, 1100, Vienna, Austria
| | - A Merrelaar
- IV Medical Department with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Kundratstraße 3, 1100, Vienna, Austria
| | - J Reiß-Kornfehl
- Department of Otorhinolaryngology, Hospital of Wiener Neustadt, Wiener Neustadt, Austria
| | - J Fussi
- Department of Internal Medicine, Cardiology and Nephrology, Hospital of Wiener Neustadt, Wiener Neustadt, Austria
| | - S Schindler
- Austrian Reference Centre for Diphtheria, Austrian Agency for Health and Food Safety, Vienna, Austria
| | - M Blaschitz
- Austrian Reference Centre for Diphtheria, Austrian Agency for Health and Food Safety, Vienna, Austria
| | - F Heger
- Austrian Reference Centre for Diphtheria, Austrian Agency for Health and Food Safety, Vienna, Austria
| | - A Indra
- Austrian Reference Centre for Diphtheria, Austrian Agency for Health and Food Safety, Vienna, Austria
| | - M Karolyi
- IV Medical Department with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Kundratstraße 3, 1100, Vienna, Austria
| | - M Staudacher
- IV Medical Department with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Kundratstraße 3, 1100, Vienna, Austria
| | - T Oelschlaegel
- IV Medical Department with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Kundratstraße 3, 1100, Vienna, Austria
| | - W Hoepler
- IV Medical Department with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Kundratstraße 3, 1100, Vienna, Austria
| | - S Neuhold
- IV Medical Department with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Kundratstraße 3, 1100, Vienna, Austria
| | - C Wenisch
- IV Medical Department with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Kundratstraße 3, 1100, Vienna, Austria
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Geusau A, Chromy D, Heissenberger D, Lippert K, Eder C, Heger F, Indra A, Willinger B, Pleininger S. Resistance profiles of Neisseria gonorrhoeae isolates in Vienna, Austria: a phenotypic and genetic characterization from 2013 to 2020. Int J Antimicrob Agents 2022; 60:106656. [PMID: 35988663 DOI: 10.1016/j.ijantimicag.2022.106656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 07/29/2022] [Accepted: 08/11/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES International surveillance data show a constant rise in the number of Neisseria gonorrhoeae infections and an increase in drug resistance of N. gonorrhoeae. As recent N. gonorrhoeae surveillance data in Austria are scarce, this study investigated phenotypic and genotypic antimicrobial resistance in N. gonorrhoeae isolates. METHODS In total, 440 N. gonorrhoeae samples were collected at the Medical University of Vienna, and the minimal inhibitory concentrations (MICs) for a range of different antibiotics were determined. Sampling sites and treatments were recorded, and whole-genome sequencing of N. gonorrhoeae isolates was performed using allele libraries to determine genotypic resistance. RESULTS The median MICs for ceftriaxone, cefixime, azithromycin, ciprofloxacin, tetracycline and penicillin were <0.002 µg/mL, <0.016 µg/mL, 0.25 µg/mL, 2.0 µg/mL, 1.5 µg/mL and 0.25 µg/mL, respectively. Annual comparison showed that MICs were generally stable for all antimicrobial agents except azithromycin, for which an increase in median MIC was observed from 2017 (0.25 µg/mL). There was no genetic resistance to ceftriaxone; 8% of samples displayed resistance mutations against cefixime, primarily located in the penA gene. Resistance to azithromycin increased from 2% in 2013 to 12% in 2020. MtrD mosaic had the highest impact on azithromycin susceptibility; 47% of the resistant isolates showed this mutation. The majority of cases of gonorrhoea were treated successfully with either ceftriaxone or a ceftriaxone/azithromycin regime. Two treatment failures occurred under monotherapy with doxycycline. Overall, genotypic resistance corresponded significantly to all respective MICs. CONCLUSIONS The resistance rate of N. gonorrhoeae to antibiotics has remained stable in Vienna over the last decade, except for azithromycin. The strong correlation found between genetic and phenotypic patterns in this study holds promise for future diagnostics of N. gonorrhoeae resistance based on genotypes.
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Affiliation(s)
- Alexandra Geusau
- Department of Dermatology, Medical University of Vienna, Vienna, Austria.
| | - David Chromy
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | | | - Kathrin Lippert
- Institute for Medical Microbiology and Hygiene, Austrian Agency for Health and Food Safety, Vienna, Austria
| | - Claudia Eder
- Institute for Medical Microbiology and Hygiene, Austrian Agency for Health and Food Safety, Vienna, Austria
| | - Florian Heger
- Institute for Medical Microbiology and Hygiene, Austrian Agency for Health and Food Safety, Vienna, Austria
| | - Alexander Indra
- Institute for Medical Microbiology and Hygiene, Austrian Agency for Health and Food Safety, Vienna, Austria; Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Birgit Willinger
- Department of Hygiene and Medical Microbiology, Division of Clinical Microbiology, Medical University of Vienna, Vienna, Austria
| | - Sonja Pleininger
- Institute for Medical Microbiology and Hygiene, Austrian Agency for Health and Food Safety, Vienna, Austria
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Traugott MT, Pleininger S, Inschlag-Tisch S, Eder B, Seitz T, Merrelaar A, Reiß-Kornfehl J, Fussi J, Schindler S, Blaschitz M, Heger F, Indra A, Karolyi M, Staudacher M, Oelschlaegel T, Hoepler W, Neuhold S, Wenisch C. A case of fulminant respiratory diphtheria in a 24-year-old Afghan refugee in Austria in May 2022: a case report. Infection 2022; 51:489-495. [PMID: 36178603 PMCID: PMC10042955 DOI: 10.1007/s15010-022-01926-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/15/2022] [Indexed: 01/15/2023]
Abstract
PURPOSE Raising awareness of respiratory diphtheria and for the importance of early antitoxin administration. METHODS Report of a case of fulminant, imported respiratory diphtheria in an otherwise healthy 24-year-old Afghan refugee in Austria in May 2022. RESULT This was the first case of respiratory diphtheria in Austria since 1993. Diphtheria antitoxin was administered at an already progressed disease stage. This delay contributed to a fulminant disease course with multiorgan failure and death. CONCLUSION In high-income countries with low case numbers, awareness of respiratory diphtheria and for the importance of early antitoxin administration must be raised.
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Affiliation(s)
- M T Traugott
- IV Medical Department with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Kundratstraße 3, 1100, Vienna, Austria.
| | - S Pleininger
- Austrian Reference Centre for Diphtheria, Austrian Agency for Health and Food Safety, Vienna, Austria
| | - S Inschlag-Tisch
- Department of Internal Medicine, Cardiology and Nephrology, Hospital of Wiener Neustadt, Wiener Neustadt, Austria
| | - B Eder
- IV Medical Department with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Kundratstraße 3, 1100, Vienna, Austria
| | - T Seitz
- IV Medical Department with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Kundratstraße 3, 1100, Vienna, Austria
| | - A Merrelaar
- IV Medical Department with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Kundratstraße 3, 1100, Vienna, Austria
| | - J Reiß-Kornfehl
- Department of Otorhinolaryngology, Hospital of Wiener Neustadt, Wiener Neustadt, Austria
| | - J Fussi
- Department of Internal Medicine, Cardiology and Nephrology, Hospital of Wiener Neustadt, Wiener Neustadt, Austria
| | - S Schindler
- Austrian Reference Centre for Diphtheria, Austrian Agency for Health and Food Safety, Vienna, Austria
| | - M Blaschitz
- Austrian Reference Centre for Diphtheria, Austrian Agency for Health and Food Safety, Vienna, Austria
| | - F Heger
- Austrian Reference Centre for Diphtheria, Austrian Agency for Health and Food Safety, Vienna, Austria
| | - A Indra
- Austrian Reference Centre for Diphtheria, Austrian Agency for Health and Food Safety, Vienna, Austria
| | - M Karolyi
- IV Medical Department with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Kundratstraße 3, 1100, Vienna, Austria
| | - M Staudacher
- IV Medical Department with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Kundratstraße 3, 1100, Vienna, Austria
| | - T Oelschlaegel
- IV Medical Department with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Kundratstraße 3, 1100, Vienna, Austria
| | - W Hoepler
- IV Medical Department with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Kundratstraße 3, 1100, Vienna, Austria
| | - S Neuhold
- IV Medical Department with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Kundratstraße 3, 1100, Vienna, Austria
| | - C Wenisch
- IV Medical Department with Infectious Diseases and Tropical Medicine, Clinic Favoriten, Kundratstraße 3, 1100, Vienna, Austria
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Schaeffer J, Lippert K, Pleininger S, Stöger A, Hasenberger P, Stadlbauer S, Heger F, Eigentler A, Geusau A, Indra A, Allerberger F, Ruppitsch W. Association of Phylogenomic Relatedness among Neisseria gonorrhoeae Strains with Antimicrobial Resistance, Austria, 2016-2020. Emerg Infect Dis 2022; 28:1694-1698. [PMID: 35876744 PMCID: PMC9328923 DOI: 10.3201/eid2808.220071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We investigated genomic determinants of antimicrobial resistance in 1,318 Neisseria gonorrhoeae strains isolated in Austria during 2016–2020. Sequence type (ST) 9363 and ST11422 isolates had high rates of azithromycin resistance, and ST7363 isolates correlated with cephalosporin resistance. These results underline the benefit of genomic surveillance for antimicrobial resistance monitoring.
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Pleininger S, Indra A, Golparian D, Heger F, Schindler S, Jacobsson S, Heidler S, Unemo M. Extensively drug-resistant (XDR) Neisseria gonorrhoeae causing possible gonorrhoea treatment failure with ceftriaxone plus azithromycin in Austria, April 2022. Euro Surveill 2022; 27. [PMID: 35713023 PMCID: PMC9205165 DOI: 10.2807/1560-7917.es.2022.27.24.2200455] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We describe a gonorrhoea case with ceftriaxone plus high-level azithromycin resistance. In April 2022, an Austrian heterosexual male was diagnosed with gonorrhoea after sexual intercourse with a female sex worker in Cambodia. Recommended treatment with ceftriaxone (1 g) plus azithromycin (1.5 g) possibly failed. Worryingly, this is the second strain in an Asian Neisseria gonorrhoeae genomic sublineage including high-level azithromycin-resistant strains that developed ceftriaxone resistance by acquisition of mosaic penA-60.001. Enhanced resistance surveillance and actions are imperative to prevent spread.
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Affiliation(s)
| | | | - Daniel Golparian
- WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Florian Heger
- Austrian Agency for Health and Food Safety, Vienna, Austria
| | | | - Susanne Jacobsson
- WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | | | - Magnus Unemo
- Institute for Global Health, University College London, London, United Kingdom.,WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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10
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Sánchez-Busó L, Cole MJ, Spiteri G, Day M, Jacobsson S, Golparian D, Sajedi N, Yeats CA, Abudahab K, Underwood A, Bluemel B, Aanensen DM, Unemo M, Pleininger S, Indra A, De Baetselier I, Vanden Berghe W, Hunjak B, Blažić TN, Maikanti-Charalambous P, Pieridou D, Zákoucká H, Žemličková H, Hoffmann S, Cowan S, Schwartz LJ, Peetso R, Epstein J, Viktorova J, Ndeikoundam N, Bercot B, Bébéar C, Lot F, Buder S, Jansen K, Miriagou V, Rigakos G, Raftopoulos V, Balla E, Dudás M, Ásmundsdóttir LR, Sigmundsdóttir G, Hauksdóttir GS, Gudnason T, Colgan A, Crowley B, Saab S, Stefanelli P, Carannante A, Parodi P, Pakarna G, Nikiforova R, Bormane A, Dimina E, Perrin M, Abdelrahman T, Mossong J, Schmit JC, Mühlschlegel F, Barbara C, Mifsud F, Van Dam A, Van Benthem B, Visser M, Linde I, Kløvstad H, Caugant D, Młynarczyk-Bonikowska B, Azevedo J, Borrego MJ, Nascimento MLR, Pavlik P, Klavs I, Murnik A, Jeverica S, Kustec T, Vázquez Moreno J, Diaz A, Abad R, Velicko I, Unemo M, Fifer H, Shepherd J, Patterson L. Europe-wide expansion and eradication of multidrug-resistant Neisseria gonorrhoeae lineages: a genomic surveillance study. The Lancet Microbe 2022; 3:e452-e463. [DOI: 10.1016/s2666-5247(22)00044-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/15/2022] [Accepted: 02/16/2022] [Indexed: 02/07/2023] Open
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11
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Lepuschitz S, Baron S, Larvor E, Granier SA, Pretzer C, Mach RL, Farnleitner AH, Ruppitsch W, Pleininger S, Indra A, Kirschner AKT. Phenotypic and Genotypic Antimicrobial Resistance Traits of Vibrio cholerae Non-O1/Non-O139 Isolated From a Large Austrian Lake Frequently Associated With Cases of Human Infection. Front Microbiol 2019; 10:2600. [PMID: 31781080 PMCID: PMC6857200 DOI: 10.3389/fmicb.2019.02600] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/25/2019] [Indexed: 12/13/2022] Open
Abstract
Vibrio cholerae belonging to serogroups other than O1 and O139 are opportunistic pathogens which cause infections with a variety of clinical symptoms. Due to the increasing number of V. cholerae non-O1/non-O139 infections in association with recreational waters in the past two decades, they have received increasing attention in recent literature and by public health authorities. Since the treatment of choice is the administration of antibiotics, we investigated the distribution of antimicrobial resistance properties in a V. cholerae non-O1/non-O139 population in a large Austrian lake intensively used for recreation and in epidemiologically linked clinical isolates. In total, 82 environmental isolates - selected on the basis of comprehensive phylogenetic information - and nine clinical isolates were analyzed for their phenotypic antimicrobial susceptibility. The genomes of 46 environmental and eight clinical strains were screened for known genetic antimicrobial resistance traits in CARD and ResFinder databases. In general, antimicrobial susceptibility of the investigated V. cholerae population was high. The environmental strains were susceptible against most of the 16 tested antibiotics, except sulfonamides (97.5% resistant strains), streptomycin (39% resistant) and ampicillin (20.7% resistant). Clinical isolates partly showed additional resistance to amoxicillin-clavulanic acid. Genome analysis showed that crp, a regulator of multidrug efflux genes, and the bicyclomycin/multidrug efflux system of V. cholerae were present in all isolates. Nine isolates additionally carried variants of bla CARB-7 and bla CARB-9, determinants of beta-lactam resistance and six isolates carried catB9, a determinant of phenicol resistance. Three isolates had both bla CARB-7 and catB9. In 27 isolates, five out of six subfamilies of the MATE-family were present. For all isolates no genes conferring resistance to aminoglycosides, macrolides and sulfonamides were detected. The apparent lack of either known antimicrobial resistance traits or mobile genetic elements indicates that in cholera non-epidemic regions of the world, V. cholerae non-O1/non-O139 play a minor role as a reservoir of resistance in the environment. The discrepancies between the phenotypic and genome-based antimicrobial resistance assessment show that for V. cholerae non-O1/non-O139, resistance databases are currently inappropriate for an assessment of antimicrobial resistance. Continuous collection of both data over time may solve such discrepancies between genotype and phenotype in the future.
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Affiliation(s)
- Sarah Lepuschitz
- Austrian Agency for Health and Food Safety (AGES), Institute for Medical Microbiology and Hygiene, Vienna, Austria.,Research Division of Biochemical Technology, Institute of Chemical, Environmental and BioScience Engineering, Technische Universität Wien, Vienna, Austria
| | - Sandrine Baron
- French Agency for Food, Environmental and Occupational Health & Safety (ANSES), Ploufragan-Plouzané-Niort Laboratory, Ploufragan, France
| | - Emeline Larvor
- French Agency for Food, Environmental and Occupational Health & Safety (ANSES), Ploufragan-Plouzané-Niort Laboratory, Ploufragan, France
| | - Sophie A Granier
- French Agency for Food, Environmental and Occupational Health & Safety (ANSES), Fougeres Laboratory, Fougeres, France
| | - Carina Pretzer
- Institute for Hygiene and Applied Immunology - Water Microbiology, Medical University Vienna, Vienna, Austria
| | - Robert L Mach
- Research Division of Biochemical Technology, Institute of Chemical, Environmental and BioScience Engineering, Technische Universität Wien, Vienna, Austria
| | - Andreas H Farnleitner
- Research Division of Biochemical Technology, Institute of Chemical, Environmental and BioScience Engineering, Technische Universität Wien, Vienna, Austria.,Division Water Quality and Health, Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria.,Interuniversity Cooperation Centre for Water and Health, Vienna, Austria
| | - Werner Ruppitsch
- Austrian Agency for Health and Food Safety (AGES), Institute for Medical Microbiology and Hygiene, Vienna, Austria
| | - Sonja Pleininger
- Austrian Agency for Health and Food Safety (AGES), Institute for Medical Microbiology and Hygiene, Vienna, Austria
| | - Alexander Indra
- Austrian Agency for Health and Food Safety (AGES), Institute for Medical Microbiology and Hygiene, Vienna, Austria
| | - Alexander K T Kirschner
- Institute for Hygiene and Applied Immunology - Water Microbiology, Medical University Vienna, Vienna, Austria.,Division Water Quality and Health, Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria.,Interuniversity Cooperation Centre for Water and Health, Vienna, Austria
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12
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Cole MJ, Quaye N, Jacobsson S, Day M, Fagan E, Ison C, Pitt R, Seaton S, Woodford N, Stary A, Pleininger S, Crucitti T, Hunjak B, Maikanti P, Hoffmann S, Viktorova J, Buder S, Kohl P, Tzelepi E, Siatravani E, Balla E, Hauksdóttir GS, Rose L, Stefanelli P, Carannante A, Pakarna G, Mifsud F, Cassar RZ, Linde I, Bergheim T, Steinbakk M, Mlynarczyk-Bonikowska B, Borrego MJ, Shepherd J, Pavlik P, Jeverica S, Vazquez J, Abad R, Weiss S, Spiteri G, Unemo M. Ten years of external quality assessment (EQA) of Neisseria gonorrhoeae antimicrobial susceptibility testing in Europe elucidate high reliability of data. BMC Infect Dis 2019; 19:281. [PMID: 30909883 PMCID: PMC6434634 DOI: 10.1186/s12879-019-3900-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 03/12/2019] [Indexed: 11/26/2022] Open
Abstract
Background Confidence in any diagnostic and antimicrobial susceptibility testing data is provided by appropriate and regular quality assurance (QA) procedures. In Europe, the European Gonococcal Antimicrobial Susceptibility Programme (Euro-GASP) has been monitoring the antimicrobial susceptibility in Neisseria gonorrhoeae since 2004. Euro-GASP includes an external quality assessment (EQA) scheme as an essential component for a quality-assured laboratory-based surveillance programme. Participation in the EQA scheme enables any problems with the performed antimicrobial susceptibility testing to be identified and addressed, feeds into the curricula of laboratory training organised by the Euro-GASP network, and assesses the capacity of individual laboratories to detect emerging new, rare and increasing antimicrobial resistance phenotypes. Participant performance in the Euro-GASP EQA scheme over a 10 year period (2007 to 2016, no EQA in 2013) was evaluated. Methods Antimicrobial susceptibility category and MIC results from the first 5 years (2007–2011) of the Euro-GASP EQA were compared with the latter 5 years (2012–2016). These time periods were selected to assess the impact of the 2012 European Union case definitions for the reporting of antimicrobial susceptibility. Results Antimicrobial susceptibility category agreement in each year was ≥91%. Discrepancies in susceptibility categories were generally because the MICs for EQA panel isolates were on or very close to the susceptibility or resistance breakpoints. A high proportion of isolates tested over the 10 years were within one (≥90%) or two (≥97%) MIC log2 dilutions of the modal MIC, respectively. The most common method used was Etest on GC agar base. There was a shift to using breakpoints published by the European Committee on Antimicrobial Susceptibility Testing (EUCAST) in the latter 5 years, however overall impact on the validity of results was limited, as the percentage categorical agreement and MIC concordance changed very little between the two five-year periods. Conclusions The high level of comparability of results in this EQA scheme indicates that high quality data are produced by the Euro-GASP participants and gives confidence in susceptibility and resistance data generated by laboratories performing decentralised testing.
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Affiliation(s)
- Michelle J Cole
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit, National Infection Service, Public Health England, London, UK.
| | - Nerteley Quaye
- National Mycobacterium Reference Service, National Infection Service, Public Health England, London, UK
| | - Susanne Jacobsson
- WHO Collaborating Centre for Gonorrhoea and other STIs, Örebro University, Örebro, Sweden
| | - Michaela Day
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit, National Infection Service, Public Health England, London, UK
| | - Elizabeth Fagan
- United Kingdom National External Quality Assessment Service (UK NEQAS), National Infection Service, Public Health England, London, UK
| | - Catherine Ison
- Sexually Transmitted Bacteria Reference Unit (retired), Public Health England, London, UK
| | - Rachel Pitt
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit, National Infection Service, Public Health England, London, UK
| | - Shila Seaton
- United Kingdom National External Quality Assessment Service (UK NEQAS), National Infection Service, Public Health England, London, UK
| | - Neil Woodford
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit, National Infection Service, Public Health England, London, UK
| | - Angelika Stary
- Outpatients` Centre for the Diagnosis of Infectious Venero-Dermatological Diseases, Vienna, Austria
| | - Sonja Pleininger
- National Reference Centre for Gonococci, Austrian Agency for Health and Food Safety, Vienna, Austria
| | | | | | | | - Steen Hoffmann
- Department for Bacteria, Parasites and Fungi Infectious Diseases Preparedness, Statens Serum Institut, Copenhagen, Denmark
| | | | - Susanne Buder
- Laboratory for Gonococci, Vivantes Klinikum, South, Berlin, Germany
| | - Peter Kohl
- Laboratory for Gonococci, Vivantes Klinikum, South, Berlin, Germany
| | - Eva Tzelepi
- National Reference Centre for N. gonorrhoeae, Laboratory of Bacteriology of the Hellenic Pasteur Institute, Athens, Greece
| | - Eirini Siatravani
- National Reference Centre for N. gonorrhoeae, Laboratory of Bacteriology of the Hellenic Pasteur Institute, Athens, Greece
| | - Eszter Balla
- Bacterial STI Reference Laboratory, National Public Health Institute, Budapest, Hungary
| | | | - Lisa Rose
- National Gonococcal Reference Laboratory, St James's Hospital, Dublin, Ireland
| | - Paola Stefanelli
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Anna Carannante
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Gatis Pakarna
- National Microbiology Reference Laboratory, Latvian Centre of Infectious Diseases, Riga East University Hospital, Riga, Latvia
| | | | | | - Ineke Linde
- Streeklaboratorium/Bacteriologie, GGD Amsterdam, Amsterdam, The Netherlands
| | - Thea Bergheim
- Department of Medical Microbiology, Oslo University Hospital, Oslo, Norway
| | | | | | | | - Jill Shepherd
- Scottish Bacterial Sexually Transmitted Infections Reference Laboratory, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Samo Jeverica
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Julio Vazquez
- Reference Laboratory for Neisseria National Centre for Microbiology - Instituto de Salud Carlos III, Majadahonda, Spain
| | - Raquel Abad
- Reference Laboratory for Neisseria National Centre for Microbiology - Instituto de Salud Carlos III, Majadahonda, Spain
| | - Sabrina Weiss
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit, National Infection Service, Public Health England, London, UK.,Institute of Virology, Charite - Universitätsmedizin Berlin, Berlin, Germany.,European Centre for Disease Prevention and Control, Stockholm, Sweden
| | | | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and other STIs, Örebro University, Örebro, Sweden
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13
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Kirschner AKT, Pleininger S, Jakwerth S, Rehak S, Farnleitner AH, Huhulescu S, Indra A. Application of three different methods to determine the prevalence, the abundance and the environmental drivers of culturable Vibrio cholerae in fresh and brackish bathing waters. J Appl Microbiol 2018; 125:1186-1198. [PMID: 29856502 PMCID: PMC6175421 DOI: 10.1111/jam.13940] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 05/18/2018] [Accepted: 05/30/2018] [Indexed: 02/01/2023]
Abstract
Aims Three cultivation methods were used to study the prevalence and abundance of Vibrio cholerae in Eastern Austrian bathing waters and to elucidate the main factors controlling their distribution. Methods and Results Vibrio cholerae abundance was monitored at 36 inland bathing sites with membrane filtration (MF), a standard most probable number (MPN) approach and direct plating (DP). Membrane filtration yielded the most reliable and sensitive results and allowed V. cholerae detection at 22 sites with concentrations up to 39 000 CFU per 100 ml, all belonging to serogroups other than O1 and O139 and not coding for cholera toxin and toxin coregulated pilus. Direct plating turned out as an easy method for environments with high V. cholerae abundances, conductivity was the only significant predictor of V. cholerae abundance in the bathing waters at warm water temperatures. Conclusions Vibrio cholerae nonO1/nonO139 are widely prevalent in Eastern Austrian bathing waters. Instead of the standard MPN approach, MF and DP are recommended for V. cholerae monitoring. Conductivity can be used as a first easy‐to‐measure parameter to identify potential bathing waters at risk. Significance and Impact of the Study Vibrio cholerae nonO1/nonO139 infections associated with bathing activities are an increasing public health issue in many countries of the northern hemisphere. However, there are only limited data available on the prevalence and abundance of V. cholerae in coastal and inland bathing waters. For monitoring V. cholerae prevalence and abundance, reliable and simple quantification methods are needed. Moreover, prediction of V. cholerae abundance from environmental parameters would be a helpful tool for risk assessment. This study identified the best culture‐based quantification methods and a first quick surrogate parameter to attain these aims.
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Affiliation(s)
- A K T Kirschner
- Institute for Hygiene and Applied Immunology, Water Hygiene, Medical University Vienna, Vienna, Austria.,Interuniversity Cooperation Centre for Water & Health, Vienna, Austria.,Research Department Water Quality and Health, Karl Landsteiner University of Health Sciences, Krems, Austria
| | - S Pleininger
- Institute for Medical Microbiology and Hygiene, Austrian Agency for Health and Food Safety, Vienna, Austria
| | - S Jakwerth
- Institute for Hygiene and Applied Immunology, Water Hygiene, Medical University Vienna, Vienna, Austria.,Interuniversity Cooperation Centre for Water & Health, Vienna, Austria
| | - S Rehak
- Institute for Medical Microbiology and Hygiene, Austrian Agency for Health and Food Safety, Vienna, Austria
| | - A H Farnleitner
- Interuniversity Cooperation Centre for Water & Health, Vienna, Austria.,Institute of Chemical, Environmental & Bioscience Engineering, Technische Universität Wien, Vienna, Austria.,Research Department Water Quality and Health, Karl Landsteiner University of Health Sciences, Krems, Austria
| | - S Huhulescu
- Institute for Medical Microbiology and Hygiene, Austrian Agency for Health and Food Safety, Vienna, Austria
| | - A Indra
- Institute for Medical Microbiology and Hygiene, Austrian Agency for Health and Food Safety, Vienna, Austria
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