In vitro pharmacodynamics of colistin against multidrug-resistant Klebsiella pneumoniae

BACKGROUND

Resistance to colistin is emerging in multidrug-resistant Gram-negative bacteria and no solid pharmacodynamic data are available for colistin against Klebsiella pneumoniae.

METHODS

Twenty-one multidrug-resistant clinical K. pneumoniae isolates from 16 different clinical sites worldwide were employed. The genetic relatedness of these isolates was examined with PFGE. In vitro pharmacodynamic properties of colistin (sulphate) were investigated by studying the MICs, mutation prevention concentrations, time-kill kinetics, population analysis profiles and the post-antibiotic effect (PAE). Time-kill was studied with three clinical isolates plus ATCC 13883 at concentrations ranging from 0.5 to 64x MIC. The PAE was examined after 20 min of exposure of these isolates.

RESULTS

The 22 isolates belonged to 18 different PFGE groups. For susceptible isolates, colistin MICs ranged from 0.125 to 1 mg/L. Six isolates were colistin-resistant with MICs of >/=32 mg/L. Colistin heteroresistance was observed in 15 of 16 isolates considered colistin-susceptible based on MICs. For susceptible isolates, colistin showed extremely rapid killing; however, regrowth was observed as early as 2 h after treatment and substantial regrowth at 24 h even at concentrations up to 64x MIC for some isolates. Colistin exhibited no or very modest PAE against the isolates tested.

CONCLUSIONS

The data suggest that monotherapy with colistin methanesulfonate, the parenteral form of colistin, and long dosage intervals may be problematic for the treatment of infections caused by multidrug-resistant K. pneumoniae, particularly for colistin-heteroresistant strains. Further investigation on combination therapy of colistin with other antibiotics is warranted.

Comparison of virulence-associated in vitro properties of typed strains of Campylobacter jejuni from different sources

Campylobacter jejuni is a major cause of human diarrhoeal disease, but specific virulence mechanisms have not been well defined. This blinded study was undertaken with 40 C. jejuni isolates from different sources to determine their haemolytic, cytotoxic and adhesion and invasion activities towards mammalian cells. The results were correlated with source of isolation and genetic makeup by amplified fragment length polymorphism (AFLP) typing. The isolates had variable degrees of haemolytic activity against rabbit erythrocytes and cytotoxicity towards CaCo-2, HeLa and Vero cells. The data indicated that the haemolytic and cytotoxic activities were due to separate factors. A range of cytotoxicity was exhibited, whereby some strains had no activity against the target cells and others had activity against all three cell lines. Certain strains had activity against CaCo-2 cells but little or no activity against the other cells, while others exhibited the opposite phenotype. The data suggested that the cytotoxicity assay with the different cell lines may have detected more than one cytotoxin. A wide variation between isolates was observed for both adherence and invasion with all three cell lines, yet, overall, the strains showed a significantly greater invasion capacity for CaCo-2. There was no clear relationship between source of isolation or disease manifestation and possession of statistically significantly higher levels of particular virulence-associated factors although, in some cases, a correlation between cytotoxicity and cell invasion was evident. Five AFLP clusters, each representing two to eleven isolates with similar profiles, were observed at the 90 % similarity level. Some AFLP groups contained isolates with a common serotype, but each group had C. jejuni isolates from more than one source with the exception of group IV, which contained only human isolates. Isolates with high cytotoxic activity against CaCo-2 cells were confined to groups I, III and IV and a group of unrelated strains (U). Group II isolates had uniformly low cytotoxicity. Isolates in groups I, V and U were more invasive for CaCo-2 cells than isolates in groups II, III and IV. The strain differences in cytotoxicity or invasion did not correlate with source of isolation.

Antibiograms of multidrug-resistant clinical Acinetobacter baumannii: promising therapeutic options for treatment of infection with colistin-resistant strains

Multidrug-resistant Acinetobacter baumannii infection has presented a global medical challenge. The antibiograms of paired colistin-susceptible and -resistant strains revealed increased susceptibility of colistin-resistant strains to most tested antibiotics, including those that are active against only gram-positive bacteria. Synergy between colistin and rifampicin was observed in the colistin-susceptible strains. The ability to form biofilm in the colistin-resistant strains was significantly lower (P<.001) than in the parent strains. Our study provides valuable information for potential expansion of our current therapeutic options against colistin-resistant A. baumannii infection.

Surveillance of primary antibiotic resistance of Helicobacter pylori at centres in England and Wales over a six-year period (2000-2005)

Antibiotic resistance is a key factor in the failure of Helicobacter pylori eradication therapy, yet few sentinel schemes exist to monitor trends in resistance at local, national or international levels. This study aimed, over a six-year period, to monitor resistance levels of H. pylori in England and Wales to the four antibiotics used in its treatment. A total of 1,310 isolates from Gwynedd in north Wales and from mid-Essex in south-east England were collected from 2000 to 2005 and tested for susceptibilities to metronidazole, clarithromycin, amoxicillin and tetracycline. Overall, metronidazole and clarithromycin resistance rates were 28.6% and 8.3% in Gwynedd and significantly higher (36.3%, p=0.0031, and 12.7%, p=0.0112) in mid-Essex. Rates of resistance to metronidazole and clarithromycin increased in both areas over this six-year period. Resistance rates were higher in female compared with male patients (38.1% vs 26.6% for metronidazole, p<0.0001, and 12.9% vs 7.5% for clarithromycin, p=0.0024), and were higher in patients <45 years compared with those ?45 years (44.0% vs 29.0% for metronidazole, p=0.0002, and 15.0% vs 9.4% for clarithromycin, p=0.0233). This study highlights the importance of antibiotic resistance surveillance in H. pylori for providing information on local resistance rates for test and treat strategies.

In vitro pharmacodynamics of colistin against Acinetobacter baumannii clinical isolates

BACKGROUND

Colistin is being increasingly used for treatment of infections caused by multidrug-resistant Gram-negative bacteria, including Acinetobacter baumannii.

METHODS

The in vitro pharmacodynamic properties of colistin (sulphate) were investigated by studying the time-kill kinetics and the post-antibiotic effect (PAE) against multidrug-resistant, including colistin heteroresistant, A. baumannii. Time-kill was studied with four multidrug-resistant clinical isolates at concentrations ranging from 0.5 to 64 x MIC. The PAE was examined after 20 min exposure with five clinical isolates, including the four in the time-kill study, plus ATCC 19606.

RESULTS

Colistin showed extremely rapid killing in a concentration-dependent manner; but re-growth was observed as early as 3 h and substantial re-growth at 24 h even at concentrations up to 32 x MIC or 64 x MIC for some isolates. Colistin exhibited modest PAE of 1.0, 2.3 and 3.5 h at 16, 32 and 64 x MIC, respectively, against ATCC 19606. Surprisingly, negative PAE (range: -0.8 to -8.15 h) was observed for all of the five clinical isolates.

CONCLUSIONS

These findings suggest that monotherapy with colistin methanesulphonate, the parenteral form of colistin, and long dosage intervals (e.g. 24 h) may be problematic for treatment of infections caused by colistin heteroresistant A. baumannii.

Heteroresistance to colistin in multidrug-resistant Acinetobacter baumannii

Multidrug-resistant Acinetobacter baumannii has emerged as a significant clinical problem worldwide and colistin is being used increasingly as "salvage" therapy. MICs of colistin against A. baumannii indicate its significant activity. However, resistance to colistin in A. baumannii has been reported recently. Clonotypes of 16 clinical A. baumannii isolates and ATCC 19606 were determined by pulsed-field gel electrophoresis (PFGE), and colistin MICs were measured. The time-kill kinetics of colistin against A. baumannii ATCC 19606 and clinical isolate 6 were investigated, and population analysis profiles (PAPs) were conducted. Resistance development was investigated by serial passaging with or without exposure to colistin. Five different PFGE banding patterns were found in the clinical isolates. MICs of colistin against all isolates were within 0.25 to 2 microg/ml. Colistin showed early concentration-dependent killing, but bacterial regrowth was observed at 24 h. PAPs revealed that heteroresistance to colistin occurred in 15 of the 16 clinical isolates. Subpopulations (<0.1% from inocula of 10(8) to 10(9) CFU/ml) of ATCC 19606, and most clinical isolates grew in the presence of colistin 3 to 10 microg/ml. Four successive passages of ATCC 19606 in broth containing colistin (up to 200 microg/ml) substantially increased the proportion of the resistant subpopulations able to grow in the presence of colistin at 10 microg/ml from 0.000023 to 100%; even after 16 passages in colistin-free broth, the proportion only decreased to 2.1%. This represents the first demonstration of heterogeneous colistin-resistant A. baumannii in "colistin-susceptible" clinical isolates. Our findings give a strong warning that colistin-resistant A. baumannii may be observed more frequently due to potential suboptimal dosage regimens recommended in the product information of some products of colistin methanesulfonate.

Specific detection of Campylobacter jejuni from faeces using single nucleotide polymorphisms

Specimens of human faeces were tested by a rapid strategy for detection of Campylobacter jejuni lineages by the presence of specific single nucleotide polymorphisms (SNPs) based on the C. jejuni multi locus sequence typing (MLST) scheme. This strategy was derived from analysis of the MLST databases to identify clonal complex specific SNPs followed by the design of real-time PCR assays to enable identification of six major C. jejuni clonal complexes associated with cases of human infection. The objective was to use the MLST SNP-based assays for the direct detection of C. jejuni by clonal complex from specimens of human faeces, and then confirm the accuracy of the clonal complex designation from the SNP-based assays by performing MLST on the cultured faecal material, this targeted at determining the validity of direct molecular specimen identification. Results showed it was possible to identify 38% of the isolates to one of the six major MLST clonal complexes using a rapid DNA extraction method directly from faeces in under 3 h. This method provides a novel strategy for the use of real-time PCR for detection and characterization beyond species level, supplying real-time epidemiological data, which is comparable with MLST results.

Culture of Helicobacter pylori from domestic water samples--the impact of strain variation on growth on solid and in liquid media

Helicobacter pylori is an important global human pathogen and there is growing evidence from PCR assays that contaminated drinking water might be a possible source of infection in some circumstances. There are no validated protocols for direct isolation but various culture media have been developed for possible environmental sampling. Our aim here was to investigate how inter-strain variation might affect the interpretation of results with such media. Two laboratory adapted reference strains and four recent clinical isolates were tested on four solid media and in ten liquid media. Considerable variation was found between strains in their ability to recover on the different media after stress exposure (suspension in sterile tap water). Generally, clinical isolates were less robust than the laboratory-adapted strains and, overall, the former required longer recovery times. Our findings highlighted the importance of using a range of isolates for evaluations, as examination of laboratory-adapted strains alone did not provide an accurate representation of the utility of media that may be used to recover H. pylori from water.

An integrated instrumental setup for the combination of atomic force microscopy with optical spectroscopy

In recent years, the study of single biomolecules using fluorescence microscopy and atomic force microscopy (AFM) techniques has resulted in a plethora of new information regarding the physics underlying these complex biological systems. It is especially advantageous to be able to measure the optical, topographical, and mechanical properties of single molecules simultaneously. Here an AFM is used that is especially designed for integration with an inverted optical microscope and that has a near-infrared light source (850 nm) to eliminate interference between the optical experiment and the AFM operation. The Tip Assisted Optics (TAO) system consists of an additional 100 x 100-microm(2) X-Y scanner for the sample, which can be independently and simultaneously used with the AFM scanner. This allows the offset to be removed between the confocal optical image obtained with the sample scanner and the simultaneously acquired AFM topography image. The tip can be positioned exactly into the optical focus while the user can still navigate within the AFM image for imaging or manipulation of the sample. Thus the tip-enhancement effect can be maximized and it becomes possible to perform single molecule manipulation experiments within the focus of a confocal optical image. Here this is applied to simultaneous measurement of single quantum dot fluorescence and topography with high spatial resolution.

Detection of Helicobacter pylori by PCR but not culture in water and biofilm samples from drinking water distribution systems in England

AIMS

To investigate treated water distribution systems in England as a source of Helicobacter pylori.

METHODS AND RESULTS

Water and biofilms were obtained from 11 domestic and seven educational properties and from hydrants, reservoirs and water meters supplied by three water utilities. Samples were cultured on nonselective and antibiotic containing media combined with immunomagnetic separation concentration. Viable helicobacters were not detected in any of the 151 samples but Helicobacter-specific PCR assays detected DNA in 26% of samples from domestic properties, schools and hydrants with the highest frequency in biofilms (42%). Direct sequencing of six selected amplicons confirmed >95% sequence homology to H. pylori.

CONCLUSIONS

While viable helicobacters were not isolated, evidence was obtained for the presence of Helicobacter DNA, including that of H. pylori. Biofilms on surfaces within water distribution systems may act either as sites for the passive accumulation of helicobacters or as potentially important reservoirs of infection.

SIGNIFICANCE AND IMPACT OF THE STUDY

Our findings strengthen evidence that H. pylori may be transmitted through drinking water. However, there is currently no evidence that viable cells can survive the disinfection levels used in UK mains supplies and the health risk from this source remains unclear.

Evaluation of Helicobacter species in inflammatory bowel disease

BACKGROUND

Bacteria have been implicated in the pathogenesis of inflammatory bowel disease. Helicobacter species have been shown to cause colitis in animal models and have been identified in human diarrhoeal illness and Crohn's disease.

AIM

To determine whether Helicobacter species are present in human inflammatory bowel disease tissue.

METHODS

Thirty patients undergoing colonoscopy for clinical reasons were studied. Nine had Crohn's disease, 11 had ulcerative colitis and 10 had histologically normal colons. Tissue was snap-frozen at -70 degrees C. DNA was extracted and examined by five different polymerase chain reaction (PCR) assays that were either genus or species specific for Helicobacter.

RESULTS

Analyses of colonic biopsies by two Helicobacter genus-specific PCR assays, two H. pylori-specific assays and a PCR assay designed to amplify fragments of 'H. heilmannii'-like organisms demonstrated that product was not generated by any test. Internal control PCR demonstrated that PCR results for the five assays were not negative due to the presence of residual substances inhibitory to PCR.

CONCLUSIONS

Helicobacter species were not identified in this study, using multiple PCRs to eliminate the problems of non-specific cross-reaction. This suggests that Helicobacter species do not play a role in the pathogenesis of inflammatory bowel disease.

Determination of Helicobacter pylori vacA allelic types by single-step multiplex PCR

AIMS

To develop and evaluate a novel multiplex PCR assay that enables definition of Helicobacter pylori vacA allelic type in a single reaction.

METHODS AND RESULTS

Application of the one-step system to DNA extracts from 22 cultures of known vacA genotype demonstrated that it was highly accurate. Analysis of 15 matched gastric biopsy/culture pairs generated exactly correlating genotype profiles. vacA genotypes were determined from an additional 62/70 gastric biopsies from dyspeptic patients of known H. pylori positive status by the one-step assay, compared with 63/70 by the original two-reaction test. Types s1/m1, s1/m2 and s2/m2 were identified in 51.9%, 31.2% and 16.9% of biopsies, respectively.

CONCLUSIONS

The multiplex PCR system developed enables rapid one-step vacA genotyping that is accurate, easy to interpret and more economical than the alternative multiple-reaction tests. Application of this system to gastric biopsies from patients in South-east England demonstrated that s1/m1 was the most common genotype, while s1/m2 and s2/m2 were less prevalent.

SIGNIFICANCE AND IMPACT OF THE STUDY

This simple one-step system can be applied direct to antral gastric biopsies without the need for culture, thereby facilitating rapid surveillance of vacA genotype in relation to geographical location and disease status.

Screening the human protocadherin 8 (PCDH8) gene in schizophrenia

Abnormalities in synaptic connectivity and plasticity have been implicated in the pathophysiology of schizophrenia. Molecules involved in the development and maintenance of neural circuitry include the recently cloned protocadherins. Human protocadherin 8 (PCDH8) is homologous to 'arcadlin', a molecule shown to play a role in hippocampal synaptic function in the rat. The gene encoding PCDH8 maps to a region on chromosome 13 where linkage to schizophrenia has been reported. In this study, the entire expressed sequence of the PCDH8 gene and over 800 bp of the 5' flanking region were screened for polymorphisms in 30 DSM-IV schizophrenia individuals using Denaturing High Performance Liquid Chromatography (DHPLC). A total of nine single nucleotide polymorphisms were identified, including three in the first exon that are predicted to change the amino acid sequence. One polymorphism, causing the Trp7Arg change in the putative signal peptide, showed a trend towards excess of the arginine encoding allele in a case-control sample consisting of 520 DSM-IV schizophrenia patients and 535 matched controls from the UK (chi2=3.72, P [1 df]= 0.054). However, this polymorphism did not show preferential transmission to schizophrenic individuals in a separate sample of 203 proband-parent trios from Bulgaria. A second, rare single nucleotide variation, predicting the non-conservative amino acid change Glu39Ala, was found in one schizophrenic individual and their affected sibling but not in a further 352 affected individuals, nor 357 controls. These results suggest that any contribution of PCDH8 polymorphisms to schizophrenia susceptibility is likely to be weak, although the existence of rare variations of stronger effect cannot be excluded.

Surveillance and clinical relevance of vacA genotypes of Helicobacter pylori infecting dyspeptic patients in mid-Essex

The Helicobacter pylori vacuolating cytotoxin is a putative pathogenicity factor encoded by vacA, a mosaic gene with a global distribution. The vacA type prevalence and diversity of H. pylori isolated from antral gastric biopsies of 360 dyspeptic patients in mid-Essex, and of 79 patients from other locations, were investigated in order to test for links with disease severity. Mid (m)-region genotyping and subtyping by vacA HaeIII RFLP (restriction fragment length polymorphism) analysis showed that the m1 and m2 alleles were diverse, with 191 different subtypes. Variation in 44% of strains was accounted for by ten subtypes of which subtype v-1 represented a conserved core (33%) of the m1 form. Prevalence rates for combined mid and signal (s)-region genotypes were 40% for s1/m1, 46% for s1/m2, and 11% for s2/m2. Overall, vacA genotyping provided high typability and discrimination, but no specific RFLP markers could reliably predict a clinically significant presentation due to an H. pylori infection.

Molecular testing for antibiotic resistance in Helicobacter pylori

An estimated 7.5 million individuals in England and Wales are actively infected with Helicobacter pylori and hence knowledge of local resistance rates is of growing importance. Also, information on strain resistance following treatment failure is crucial in selecting an appropriate regimen as the development of bacterial resistance to antibiotics makes retreatment difficult. Molecular test methods may have an impact on improving the availability and accuracy of information on H pylori antimicrobial resistance to guide in the selection of primary as well as secondary backup treatment regimens.

Impact of transport crate reuse and of catching and processing on Campylobacter and Salmonella contamination of broiler chickens

The influence of transport, catching, and processing on contamination of broiler chickens with Salmonella and Campylobacter was investigated. Transport crates were reused with high frequency and were often still contaminated with Salmonella and Campylobacter when they arrived at the farm despite the fact that they were washed at the factory, and thus they were a potential route of infection. These organisms contaminated the feathers of previously Campylobacter- and Salmonella-negative birds going to the processing plant and were isolated from processed carcasses, albeit at a low frequency. The Campylobacter types which were the predominant organisms on the live birds when they arrived at the processing plant were not necessarily the types that were most frequently isolated from processed carcasses. This finding may reflect cross-contamination that occurred during processing or differences in the tolerance of the strains to the hostile environments that the bacteria experienced. The process of catching and putting the birds in crates significantly increased the chance of contamination with Campylobacter (P < 0.001).

Searching for susceptibility genes in schizophrenia

The existence of an important genetic contribution to the aetiology of schizophrenia is well established from genetic epidemiological studies. However, the mode of transmission is complex and non-Mendelian. The main approaches used to identify susceptibility genes are linkage and association studies and the study of cytogenetic abnormalities associated with or linked to schizophrenia. Many linkage studies have been reported but have failed as yet to produce unequivocal, replicated demonstrations of linkage. However, modest evidence for several regions has been reported in more than one data set. Areas implicated include chromosome 22q11-12, 6p24-22, 6q, 8p22-21, 13q14.1-q32 and 1q21-q22, but in every case there are positive as well as negative findings. Most candidate gene studies have been based upon neuropharmacological studies suggesting that abnormalities in monoamine neurotransmission play a role in the aetiology of schizophrenia. Overall, the results have been disappointing, but it should be noted that the sample sizes in many of the older studies would now generally be regarded as inadequate. Finally, recent work has suggested that velo-cardio-facial syndrome (VCFS) is associated with rates of psychosis possibly as high as 30%. VCFS is caused by small interstitial deletions of chromosome 22q11 in 80-85% of individuals. Work is now under way to try and identify whether a gene or genes within the deleted region are of more general relevance to schizophrenia. Future directions in schizophrenia research include collecting larger samples to increase power of findings and applying novel methods for large-scale genotyping of single-nucleotide polymorphisms.

Conservation and microdiversity of the phospholipase A (pldA) gene of Helicobacter pylori infecting dyspeptics from different countries

Phospholipase activity is important in bacterial pathogenicity and could contribute to the pathogenic role of Helicobacter pylori by degradation of the gastric mucus, and in maintaining long-term colonisation. Our aim was to determine the degree of variation in the phospholipase A gene (pldA) of H. pylori from different geographic locations, and to investigate links between pldA genotype and clinical disease severity, as well as with variation in cagA status and vacA genotypes. PCR-restriction fragment length polymorphism (RFLP) analysis with MboI and HaeIII was used to study 124 isolates from 10 countries that included the two genome-sequenced strains (26695 and J99), as well as Tx30a and NCTC 11637 (type strain). The 925-bp pldA fragment was amplified with a frequency of 90%. The presence of pldA was confirmed in the other strains using an alternative forward primer. Isolates were distinguished by PCR-RFLP analysis with 10 MboI and four HaeIII restriction patterns that combined to give 25 distinct pldA RFLP types. The pldA M2H2 strain genotype was most common (20%) in the UK but similar strains came from several other countries. Microdiversity was evident in pldA sequences of strains representing different RFLP types, and five M2H2 strains each had a distinct pldA sequence type. Intragenic variation was independent of gastric disease severity as well as strain cagA status and vacA genotype, with the exception of eight geographically diverse strains all with the pldA M4H3/cagA+/vacA s1m1 genotype predominantly from peptic ulcer patients. The study indicated a spectrum of genotypic variants and was supportive of a pldA function in H. pylori colonisation and persistence rather than in chronicity of infection.

Differentiation of metronidazole-sensitive and -resistant clinical isolates of Helicobacter pylori by immunoblotting with antisera to the RdxA protein

Antimicrobial resistance in Helicobacter pylori is a serious and increasing problem, and the development of rapid, reliable methods for detecting resistance would greatly improve the selection of antibiotics used to treat gastric infection with this organism. We assessed whether detection of the RdxA protein could provide the basis for determining the susceptibility of H. pylori to metronidazole. In order to raise polyclonal antisera to RdxA, we cloned the rdxA gene from H. pylori strain 26695 into the commercial expression vector pMAL-c2, purified the resultant fusion protein by affinity chromatography, and used this recombinant RdxA preparation to immunize rabbits. We then used this specific anti-RdxA antibody to perform immunoblotting on whole bacterial cell lysates of 17 metronidazole-sensitive and 27 metronidazole-resistant clinical isolates of H. pylori. While a 24-kDa immunoreactive band corresponding to the RdxA protein was observed in all metronidazole-sensitive strains, this band was absent in 25 of 27 resistant isolates. Our results indicate that testing for the absence of the RdxA protein would identify the majority of clinical isolates that will respond poorly to metronidazole-containing eradication regimens and have implications for the development of assays capable of detecting metronidazole resistance in H. pylori.

Measurement of long-range steric repulsions between microspheres due to an adsorbed polymer

We have measured the interparticle potential between pairs of micron-sized silica spheres induced by adsorbed polyethylene oxide polymer using a line-scanned optical tweezer. We found this long-range steric repulsion to be exponential over the range of energies (0.1k(B)T-5k(B)T) and polymer molecular weights (452,000-1,580,000) studied, and that the potential scaled with the polymer's radius of gyration R(G). The potential's exponential decay length was about 0.6R(G) and its range was about 4R(G), although both parameters varied significantly from one pair of spheres to another. The potential's exponential prefactor was greater than mean-field predictions.

High-Q dynamic force microscopy in liquid and its application to living cells

We present a new dynamic force microscopy technique for imaging in liquids in the piconewton regime. The low quality factor (Q) of the cantilever is increased up to three orders of magnitude by the implementation of a positive feedback control. The technique also includes a phase-locked loop unit to track the resonance of the cantilever. Experiments and computer simulations indicate that the tip-sample forces are below 100 pN, about two orders of magnitude lower than in conventional tapping mode atomic force microscopy. Furthermore, the spectroscopic ability is greatly enhanced. Either the phase shift or the resonant frequency shows a high sensitivity to variations in either the energy dissipation or conservative interactions between the tip and the sample, respectively. The potential of this technique is demonstrated by imaging living cells.

Amplified fragment length polymorphism genotyping of metronidazole-resistant Helicobacter pylori infecting dyspeptics in England

OBJECTIVE

Intra-specific diversity of Helicobacter pylori infecting stomachs of different individuals was investigated by numerical analysis of amplified fragment length polymorphisms (AFLP), to determine the existence of clones within the strain population and the effect that antibiotic treatment, particularly with metronidazole (Mtz), had on the balance of types/subtypes present before and after treatment.

METHODS

The 92 cultures studied comprised 89 single or multiple (pre- and post-treatment) isolates from gastric biopsies from 35 dyspeptic patients at two geographical locations in England, and three reference strains. HindIII restriction fragments tagged with specific adaptors were used as template DNA for AFLP. Patterns were coded in binary format according to deduced sizes of amplified fragments, and numerical analysis was performed.

RESULTS

H. pylori isolated from different individuals were highly diverse (43 AFLP types) with a continuum of similarities that included three putative strain clusters at the 55% similarity level. Twelve sets each comprised identical isolates but subclonal variants with similarities of 82-99% coexisted in isolate sets from 19 patients. Seven sets contained strains with different AFLP types which for several corresponded with vacA/cagA genotypic differences. Mtz resistance was a feature of clonal as well as unrelated isolates.

CONCLUSIONS

AFLP profiling was a robust, reproducible and highly discriminatory means of indexing H. pylori strain diversity, and the numerical analysis enabled clonal/subclonal variants infecting an individual to be defined and contrasted with the general species diversity. The majority (65%) of patients had co-infections with different strain types/subtypes but antibiotic treatment apparently did not markedly modify H. pylori population diversity in individual stomachs. Mtz sensitivity was generally associated with greater strain diversity as several subtypes often coexisted in sensitive pretreatment strain sets. In contrast, Mtz-resistant strain populations were less diverse, which was attributed to selection by previous exposure to nitroimidazoles in the same or a different host.

PCR-based diagnosis of Helicobacter pylori infection and real-time determination of clarithromycin resistance directly from human gastric biopsy samples

A novel PCR detection assay that amplifies the Helicobacter pylori-specific vacuolating cytotoxin gene (vacA) and thus enables rapid diagnosis of infection is described. Additionally, a real-time probe hybridization melting point analysis assay to detect all three mutations in the 23S rRNA gene associated with clarithromycin resistance was applied directly to antral gastric biopsy samples. Comparison with culture and an alternative PCR assay targeting the 16S rrn gene showed that the vacA assay was sensitive and specific when tested on biopsy samples from 121 patients. Clarithromycin susceptibilities could be determined in the majority (92.3%) of culture-positive gastric biopsy samples analyzed, four of which generated melting peaks indicative of clarithromycin resistance by either an A-->G or A-->C mutation. The presence of the mutations correlated with the clarithromycin disk diffusion sensitivities of matched cultures. This PCR-based system was simple to perform and could be completed in 3 to 4 h, thereby overcoming the delays associated with conventional culture methods for H. pylori identification and susceptibility testing.

Genetic diversity in the Helicobacter pylori cag pathogenicity island and effect on expression of anti-CagA serum antibody in UK patients with dyspepsia

AIMS

To investigate variation within the cag pathogenicity island (PAI) of Helicobacter pylori isolated from patients with dyspepsia in mid-Essex, and to evaluate the effect on expression of anti-CagA antibody.

METHODS

Sixty two isolates of H pylori cultured from gastric biopsies were screened by specific PCR assays for the presence of cagA and other gene markers (cagD and cagE, and virD4) in the cag PAI. An enzyme linked immunosorbent assay (ELISA) kit (Viva Diagnostica helicobacter p120) was used to test for anti-CagA IgG antibody in matching sera. Isolates were also genotyped by vacuolating cytotoxin polymerase chain reaction (PCR) analysis, and tested for absence of the complete cag PAI (empty site PCR assay).

RESULTS

Forty one of the H pylori isolates had a cag PAI containing cagA. One strain had no cagA but other cag PAI loci were present, whereas the remaining 20 strains had no detectable cag PAI markers. Anti-CagA IgG antibody was detected in 34 sera by the ELISA assay, and when compared with the cag PAI genotype of the infecting strain, accuracy, sensitivity, and specificity were 92%, 87%, and 100%, respectively. The seven discrepant or borderline strains in the ELISA were all vacA s1 but differed in other genotypic markers.

CONCLUSIONS

The cag PAI was widely distributed in H pylori from patients with dyspepsia in mid-Essex who had different gastric pathologies. Infection with a strain having an uninterrupted cag PAI was associated with the presence of anti-CagA antibody in most patients. Discrepant ELISA results, mostly for elderly patients with duodenal ulcers, were attributed to cagA associated variation, particularly to the presence of mixed cagA+/cagA- cell variants in the infecting strain population. Tests for anti-CagA serum antibody were unreliable for predicting severity of clinical disease associated with H pylori infection in this series of patients.

Analysis of host responses of guinea pigs during Helicobacter pylori infection

Host responses of guinea pigs infected with Helicobacter pylori were investigated. Passaged H. pylori colonised the stomach for up to 13 weeks after infection, but after 1 month the number of bacteria fell sharply. Specific antibodies, predominantly of the IgG2 subtype, were present from week 3 onwards. Antibodies to urease A and flagella were abundant. Severe inflammation of the gastric mucosa and damage to the stomach epithelium was seen. Infiltrates of mononuclear cells and eosinophils were found near the parietal glands. As infection progressed, inflammation and tissue damage became more localised and more variable between individual animals. These parameters can be used as markers for colonisation of the stomach by H. pylori.

Molecular epidemiology of Helicobacter pylori in England: prevalence of cag pathogenicity island markers and IS605 presence in relation to patient age and severity of gastric disease

The cagA gene is a key marker for the Helicobacter pylori cag pathogenicity island (PAI), which may vary in composition in different strains with insertion sequence mediated interruptions and deletions of genes. While presence of cagA has been associated with increased risk for peptic ulcer disease and gastric cancer, the precise link with virulence is controversial. We investigated H. pylori from dyspeptics in one location in England (mid-Essex) with reference to the prevalence and distribution by age cohort of different cag PAI forms to determine if presence of the insertion element IS605 had a modifying effect on the severity of associated disease. H. pylori isolated from gastric biopsies over a 4-year period were screened by specific PCR assays for the presence of cagA, cagD, cagE and virD4 genes in the cag PAI, and for the presence of IS605 in the PAI and elsewhere in the genome. Most (68%) of the 166 isolates of H. pylori contained a PAI based on detection of cagA whereas 29% had no detectable PAI using multiple loci. The cagA+ genotype frequencies were similar in the peptic ulcer and non-ulcer dyspepsia-gastritis groups (79% vs. 74%) whereas frequencies in the NUD-oesophagitis and normal mucosa groups were lower (58%) but not significantly different (P>0.41). Genomic IS605 inserts were present at an overall frequency of 32% and were widely distributed with respect to patient age and disease severity. The combined cagA+/IS- strain genotype was common but not significantly associated with PUD compared to endoscopically normal mucosa (P> or =0.807). We concluded that presence of the IS605 element, whether in cagA+ or cagA- strains of H. pylori, did not systematically modify the severity of associated disease in the study population.

Human serum antibody response to Helicobacter pylori whole cell antigen in an institutionalized Bangladeshi population

AIMS

To use a commercial ELISA kit and an immunoblot assay to investigate the antibody levels of selected members of the Bangladeshi population to Helicobacter pylori protein antigens.

METHODS AND RESULTS

Using immunoblotting, high seroprevalence rates were observed in all age groups, although the subjects within the 1-9 years age group had the highest seroprevalence of antibodies to H. pylori antigens. By ELISA, the highest level of seroprevalence was observed in those over the age of 20 years.

CONCLUSION

On the basis of these results the overall prevalence rate of H. pylori infection for the whole population was 77.4%; 77.9% for orphan boys and 76% for carers. CagA antibodies were detected in 86% of those with high levels of antibodies to H. pylori antigens.

SIGNIFICANCE AND IMPACT OF THE STUDY

A combination of immunoblotting and ELISA was the most efficient means of detecting serum antibodies to H. pylori antigens and could be applied to the screening of human sera for H. pylori-specific antibodies.

Percutaneous ablation of peripheral pseudoaneurysms using thrombin: a simple and effective solution

PURPOSE

To assess the effectiveness of tissue adhesive and thrombin solution in the percutaneous ablation of peripheral artery pseudoaneurysms.

METHODS

Twenty-five pseudoaneurysms were treated over a 33-month period; all had failed ultrasound-guided compression. Tissue adhesive or thrombin solution was injected percutaneously, with needle tip position and changes within the aneurysm confirmed with color Doppler ultrasound. In 19 cases we utilized a protective balloon inflated across the aneurysm neck prior to the injection of tissue adhesive and in six cases used thrombin injection alone. Seven patients were anticoagulated. Patients were followed up after the procedure.

RESULTS

All 25 aneurysms were treated successfully; two patients required a return visit and there were no immediate complications or peripheral emboli detected. One patient developed a contralateral pseudoaneurysm.

CONCLUSIONS

The percutaneous injection of pseudoaneurysms is a safe, atraumatic, and effective treatment for femoral artery pseudoaneurysms in the peripheral circulation. There are significant advantages over ultrasound-guided compression or surgical repair.

Percutaneous ablation of an internal iliac aneurysm using tissue adhesive

We report the percutaneous injection of tissue adhesive (Tisseal, Immuno, Vienna, Austria) to ablate a 12-cm internal iliac aneurysm. The complex history of this lesion included previous surgery for a ruptured aortic aneurysm, attempted repair of the internal iliac aneurysm, and several embolization procedures. These factors precluded further open repair or transcatheter techniques and dictated the choice of a more direct approach.

In vivo degradation of tungsten embolisation coils

It has been suggested that tungsten embolisation coils in intracranial aneurysms may dissolve in situ. These coils are also used, in much larger quantities, for the occlusion of larger vessels outside the cranium. This study was performed to investigate whether tungsten embolisation coils may become degraded in vivo and to examine whether this is radiographically evident on medium-term follow-up. 10 patients who had undergone aortic stent-graft repair of an abdominal aortic aneurysm (8 male and 2 female, mean age 69.7 years) and 10 age- and sex-matched controls were studied. The study group had also received an average of 64 cm of tungsten coil either to prevent or to treat an endoleak. Whole blood, serum and urine tungsten levels were assayed. Immediate post-operative and follow-up abdominal radiographs were reviewed by two consultant vascular radiologists to detect visible changes in the coils. Whole blood, serum and urine levels of tungsten were highly and significantly elevated (p < 0.001) in the study group compared with the controls. No radiographic changes in the coils were seen at an average of 16.7 months. In conclusion, tungsten embolisation coils dissolve in humans but radiographic changes are not apparent on medium-term follow-up. The clinical significance of these findings is uncertain but long-term follow-up is needed.

Endovascular treatment of a portal vein tear during TIPSS

During a transjugular portosystemic stent-shunt (TIPSS) procedure a portal vein laceration occurred with subsequent intraperitoneal hemorrhage. A PTFE-covered nitinol stent was successfully placed eliminating the leak and creating a functioning portosystemic shunt. This case demonstrates both the importance of portal vein puncture more than 1 cm from the bifurcation and the necessity of maintaining a stock of available stent-grafts.

Effect of clarithromycin and omeprazole therapy on the diversity and stability of genotypes of Helicobacter pylori from duodenal ulcer patients

The genotypes of multiple isolates of Helicobacter pylori from 17 duodenal ulcer patients in the United Kingdom were compared to determine reasons for treatment failure. Isolates were from antrum and corpus biopsies taken before and after dual therapy with clarithromycin and omeprazole. All isolates were tested for antibiotic resistance and characterised by a novel scheme combining polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis of the ureA + ureB and 23S rRNA genes, vacA signal and midregion genotypes, and PCR detection of cagA. Combined genotypes of paired pre- and post-treatment isolates from 8 patients showed an infection with a single strain of H. pylori that had acquired resistance to clarithromycin. In 4 other patients, acquisition of clarithromycin resistance was associated with the presence of different strain types of H. pylori. The remaining 5 patients had clarithromycin-sensitive isolates. Overall, H. pylori from different patients had diverse genotypes, yet most (70%) were colonized by the same predominant and stable strain in both the antrum and corpus. There was no link between the emergence of in vitro clarithromycin resistance and a particular strain genotype for these UK isolates. It was concluded that colonization with a clarithromycin-resistant H. pylori was due to selection of a resistant strain or clonal variant within the infecting population. Present genomic markers had low predictive value for emergence of resistance.

Conservation of the cag pathogenicity island of Helicobacter pylori: associations with vacuolating cytotoxin allele and IS605 diversity

BACKGROUND & AIMS

Specific regions of the cag pathogenicity island (PAI) believed to enhance the virulence of Helicobacter pylori, as well as vacuolating cytotoxin gene alleles and IS605 inserts, were investigated to define diversity within infecting strain populations from patients with peptic ulcer disease and from healthy individuals.

METHODS

The H. pylori studied comprised 67 isolates from 26 subjects and 14 reference strains. Specific polymerase chain reaction assays were used to test for cagA and picB in the cagI region, the virD4 homologue in the cagII region, IS605 in the genome and in the cag PAI, the "empty site" indicating absence of the cag PAI, and different vacA gene alleles.

RESULTS

Most (89%) subjects were infected by H. pylori with a contiguous cag PAI. No intermediate forms were found. IS605 was not detected within the cag PAI of any strain but was present elsewhere in the genomes of strains from 62% of subjects. Twenty individuals were infected with genotypically conserved populations of H. pylori. Six subjects had mixed infections, and in 3 of these cag(+)/cag(-) variants were present.

CONCLUSIONS

The cag PAI-positive H. pylori was a feature of most infected individuals, irrespective of severity of associated disease. Combined genotyping showed that 8 individuals (31%) had mixed infections, which suggests that strain population structure may be an additional contributing factor in disease development.

Novel method for rapid determination of clarithromycin sensitivity in Helicobacter pylori

A novel PCR-hybridization assay, performed in single closed capillaries, was developed to detect clarithromycin resistance-associated gene mutations in Helicobacter pylori. Mutations were detected by thermal analysis in 33 of 34 (97%) resistant isolates but not in 66 isolates determined to be sensitive by conventional antibiotic assays. The method was rapid and reproducible, and it reduced PCR product contamination risk.

Genetic diversity in Helicobacter pullorum from human and poultry sources identified by an amplified fragment length polymorphism technique and pulsed-field gel electrophoresis

Helicobacter pullorum was first isolated from the faeces and carcasses of poultry and has been associated with human gastroenteritis. The aim of this study was to examine interstrain genetic diversity within H. pullorum. Two fingerprinting techniques were used: amplified fragment length polymorphism (AFLP) and pulsed field gel electrophoretic (PFGE) analysis. The 20 strains examined were from four countries and comprised 13 human isolates and seven poultry isolates. Their identity was confirmed by a species-specific PCR assay. The human and poultry isolates had distinct genotypes and most strains showed a high degree of genetic diversity. Genotyping also indicated a clonal origin for two strains from the same poultry flock, and established a close relatedness between three chicken carcass isolates from a processing plant. It is concluded that these two genotyping techniques will provide a useful basis for future epidemiological investigations of H. pullorum in poultry, and may provide a link with its possible causal role in human gastrointestinal infections.

The effect of omeprazole dosing on the isolation of Helicobacter pylori from gastric aspirates

BACKGROUND

Animal experiments suggest that omeprazole dosing increases shedding of Helicobacter into the gastric lumen, and hence into gastric juice.

AIM

To assess the effect of omeprazole dosing on the yield of H. pylori from gastric aspirates of infected volunteers.

METHODS

Six serial nasogastric aspirates, three before and three during dosing with omeprazole 40 mg b.d., were obtained for culture from 10 H. pylori infected volunteers and one uninfected volunteer. To reduce contamination, samples were diluted 1:10 with Maximum Recovery Diluent (MRD; pH 7.0) or HCl-KCl buffer (pH 2.2) prior to culture on Columbia and Dent's agar.

RESULTS

Undiluted gastric juice cultures were rapidly overgrown by upper respiratory tract flora. HCl-KCl dilution resulted in isolation of H. pylori from 77% of infected subject aspirates before, and 67% of aspirates during dosing with omeprazole. The yields were significantly lower with MRD dilution, 47% and 10%, respectively. Omeprazole dosing significantly decreased the yield after MRD dilution, but not after HCl-KCl dilution.

CONCLUSIONS

Decreasing intragastric acidity, by dosing with omeprazole, decreases the isolation of H. pylori from routinely processed gastric aspirates. In vitro acidification of gastric aspirates, by HCl-KCl dilution, increases the isolation of H. pylori both before and during omeprazole dosing.

Restriction fragment length polymorphism analysis of the flaA gene of Campylobacter jejuni for subtyping human, animal and poultry isolates

233 strains of Campylobacter jejuni were subtyped by PCR-RFLP analysis of the flagellin (flaA) gene by double digestion with EcoRI and PstI (EP flaA-profiling). The strains represented a variety of common Penner heat stable (HS) serotypes and comprised isolates of human, bovine, ovine, chicken and canine origin. FlaA amplicons were obtained directly from DNA in cell lysates of most strains. RFLP analysis showed considerable allelic variation and nine EP flaA-types were identified of which the most common were type 2 (32%), type 3 (20%), type 4 (12%) and type 6 (12%). Other flaA-profiles each represented less than 10% of strains. C. jejuni strains of each serotype generally had one or two specifically associated flaA-types although some were features of several serotypes. Strains with the same flaA-type were found in different hosts. EP flaA-profiles were reproducible, clear and simple to record, and laboratory protocols were rapid and low cost with high throughput capacity. The EP flaA-profiling scheme provided an excellent molecular subtyping method to supplement HS serotyping, and reference strains are recommended to facilitate its use in future epidemiological investigations.

A study of infectious intestinal disease in England: microbiological findings in cases and controls

A study was undertaken to identify the microorganisms and toxins in stool specimens associated with infectious intestinal disease (IID) among cases in the community and presenting to general practitioners (GPs) and in asymptomatic controls. Population based cohorts were recruited from practice lists in 70 practices and followed for 26 weeks (cohort component). Seven hundred and sixty-one cases of IID identified from the cohorts, 2893 cases who presented to GPs in 34 of the practices (GP component), and age/sex matched control subjects (555 and 2264, respectively) submitted stool specimens by post for comprehensive microbiological examination. Campylobacter spp (12.2% of stools tested), rotavirus group A (7.7%), and small round structured virus (SRSV) (6.5%) were the organisms most commonly detected in the GP component. SRSV was identified in 7.0% of cases in the community cohort. No target microorganisms or toxins were identified in 45.1% and 63.1% of cases in the two components. Aeromonas spp, Yersinia spp, and some enterovirulent groups of Escherichia coli were detected as frequently in controls as in cases. The higher frequency of detection of campylobacter, salmonella, and rotavirus among cases who presented to GPs than among those in the community suggests that those pathogens cause more severe illness. No enteropathogens were detected from a large proportion of cases although comprehensive standard methods were used to seek them.

Development of a scheme for genotyping Helicobacter pylori based on allelic variation in urease subunit genes

Helicobacter pylori urease subunit genes in 383 isolates from 10 countries were investigated by PCR-restriction fragment length polymorphism (HaeIII) analysis. Eighty-two different ureAB profiles were documented by reference to known sequences. Variation among 51% of strains was accounted for by 10 predominant patterns, which provided a unique framework for categorizing isolates with geographically diverse origins.