Genetic relatedness, antibiotic resistance, and virulence of Klebsiella pneumoniae isolated from healthcare and food sources in Wuhan, China

OBJECTIVE

To investigate genetic relatedness and antibiotic resistance of Klebsiella pneumoniae from retail meat samples, clinical source samples, and hospital environmental samples in Wuhan, China.

METHODS

The hypermucoviscosity phenotypes and biofilm formation ability of K. pneumoniae were determined by string test and crystalline violet staining. The minimal inhibitory concentrations of 18 antimicrobial agents were determined by the broth microdilution test, and PCR assays were performed to detect 14 genes associated with antibiotic resistance. Pulsed-field gel electrophoresis (PFGE) analysis was used to assess the genetic relatedness and clonal dissemination.

RESULTS

Among the 5730 samples analyzed, 46 tested positive for K. pneumoniae, with higher rates observed in meat (23.4%, CI: 12.8-38.4%) than in clinical samples (0.6%, CI: 0.4-0.8%) and hospital environmental samples (8.0%, CI: 2.6-20.1%). Meat-derived isolates showed high resistance to tetracycline (36.4%, 4/11, CI: 12.4-68.4%), sulphonamide (27.3%, 3/11, CI: 7.3-60.7%), and gentamicin (27.3%, 3/11, CI: 7.3-60.7%), whereas clinical isolates exhibited significant resistance to ampicillin-sulbactam (32.3%, 10/31, CI: 17.3-51.5%). Multidrug resistance was observed in 17.4% (8/46, CI:8.3-32.0%) of the isolates, particularly in hospital environmental samples (3/4, CI: 21.9-98.7%). Biofilm production was observed in 88.1% (37/42, CI: 73.6-95.6%) of K. pneumoniae, with varying degrees of strength. PFGE analysis revealed patient-to-patient K. pneumoniae transmission, transmission between patients and hospital environment, as well as cross-contamination between markets.

CONCLUSION

The findings underscore the importance of comprehensive surveillance, infection control and judicious antibiotic use in mitigating the impact of K. pneumoniae on public health, especially in food chain and healthcare settings.

Detection of virulence genes of Staphylococcus aureus isolated from raw beef for retail sale in the markets of Ulaanbaatar city, Mongolia

BACKGROUND

Staphylococcus aureus (S. aureus) is a highly virulent pathogen that causes food-borne illness, food poisoning, skin and soft tissue infections, abscesses, mastitis, and bacteremia. It is common for meat and meat products to become contaminated with S. aureus due to dirty hands, food storage conditions, food production processes, and unhygienic conditions, causing food poisoning. Therefore, we aimed to isolate S. aureus strain from the raw beef and reveal virulence genes and antibiotic resistance profile from isolated S. aureus strains.

METHODS

In this study, 100 samples of raw beef were collected from 4 major market stalls in Ulaanbaatar city, Mongolia. S. aureus was detected according to the ISO 6888-1:2021 standard, and the nucA gene encoding the species-specific thermonuclease was amplified and confirmed by polymerase chain reaction (PCR). In the strains of S. aureus isolated from the samples, the genes encoding the virulence factors including sea, sed, tsst, eta, etb, and mecA were amplified by multiplex PCR. These genes are encoded staphylococcal enterotoxin A, enterotoxin D, toxic shock syndrome toxin, exotoxin A, exotoxin B and penicillin-binding protein PBP 2A, respectively. Antibiotic sensitivity test was performed by the Kirby-Bauer disc diffusion method. The Clinical and Laboratory Standard Institute guidelines as CLSI M100-S27 was used for analysis of the data.

RESULTS

Thirty-five percent of our samples were detected contaminated with of the S. aureus strains. Subsequently, antibiotic resistance was observed in the S. aureus contaminated samples. Among our samples, the highest rates of resistance were determined against ampicillin (97.1%), oxacillin (88.6%), and penicillin (88.6%), respectively. Three genes including mecA, sea, and tsst from six virulence genes were detected in 17% of S. aureus strain-contaminated samples by multiplex PCR. The sed, etb and eta genes were detected in the 2.9%, 11.4% and 5.7% of our samples, respectively.

CONCLUSION

The results show that S. aureus related contamination is high in the raw beef for retail sale and prevalent S. aureus strains are resistant to all antibiotics used. Also, our results have demonstrated that there is a high risk for food poisoning caused by antibiotic resistant S. aureus in the raw beef and it may establish public health issues. Genes encoding for both heat-resistant and nonresistant toxicity factors were detected in the antibiotic resistant S. aureus strains and shown the highly pathogenic. Finally, our study is ensuring to need proper hygienic conditions during beef's preparation and sale.

Impact of irradiation on physico-chemical and nutritional properties of fruits and vegetables: A mini review

Background

Fruits and vegetables are healthy because they contain good nutrients and secondary metabolites that keep the body healthy and disease-free. Post-harvest losses of fresh fruits and vegetables limit access and availability as a result of foodborne infections and poor storage technologies. The selection of fruits and vegetables depend on the starting microbial load, the size of fruits and vegetables, and the type of infrastructure.

Scope and approach

Despite the positive impacts of conventional thermal (roasting, boiling, blanching) and some non-thermal processing techniques such as High Pressure Processing (HPP), Pulse Electric Field (PEF), Cold Plasma Technology (CPT) on shelf-life extension, their use is commonly associated with a number of negative consequences on product quality such as cold plasma treatment increases the acidity and rate of lipid oxidation and further decrease the colour intensity and firmness of products. Similarly, in high pressure processing and pulse electric field there is no spore inactivation and they further limit their application to semi-moist and liquid foods. On that account, food irradiation, a non-thermal technique, is currently being used for post-harvest preservation, which could be very useful in retaining the keeping quality of various fresh and dehydrated products without negatively affecting their versatility and physico-chemical, nutritional and sensory properties.

Conclusion

Existing studies have communicated the effective influence of irradiation technology on nutritional, sensory, and physico-chemical properties of multiple fruits and vegetables accompanying consequential deduction in microbial load throughout the storage period. Food irradiation can be recognized as a prevalent, safe and promising technology however, still is not fully exploited on a magnified scale. The consumer acceptance of processed products has always been a significant challenge for innovative food processing technologies such as food irradiation. Therefore, owing to current review, additional scientific evidences and efforts are still demanded for increasing its technological request.

The accumulation of Vγ4 T cells with aging is associated with an increased adaptive Vγ4 T cell response after foodborne Listeria monocytogenes infection of mice

BACKGROUND

It is generally accepted that aging has detrimental effects on conventional T cell responses to systemic infections. However, most pathogens naturally invade the body through mucosal barriers. Although mucosal sites are highly enriched in unconventional immune sentinels like γδ T cells, little is currently known about the impact of aging on unconventional mucosal T cell responses. We previously established that foodborne infection with a mouse-adapted internalin A mutant Listeria monocytogenes (Lm) generates an adaptive intestinal memory CD44^hi CD27^neg Vγ4 T cells capable of co-producing IL-17A and IFNγ. Therefore, we used this model to evaluate the impact of aging on adaptive Vγ4 T cell responses elicited by foodborne infection.

RESULTS

Foodborne Lm infection of female Balb/c and C57BL/6 mice led to an increased adaptive CD44^hi CD27^neg Vγ4 T cell response associated with aging. Moreover, Lm-elicited CD44^hi CD27^neg Vγ4 T cells maintained diverse functional subsets despite some alterations favoring IL-17A production as mice aged. In contrast to the documented susceptibility of aged mice to intravenous Lm infection, mice contained bacteria after foodborne Lm infection suggesting that elevated bacterial burden was not a major factor driving the increased adaptive CD44^hi CD27^neg Vγ4 T cell response associated with mouse age. However, CD44^hi CD27^neg Vγ4 T cells accumulated in naïve mice as they aged suggesting that an increased precursor frequency contributes to the robust Lm-elicited mucosal response observed. Body mass did not appear to have a strong positive association with CD44^hi CD27^neg Vγ4 T cells within age groups. Although an increased adaptive CD44^hi CD27^neg Vγ4 T cell response may contribute to foodborne Lm resistance of C57BL/6 mice aged 19 or more months, neither anti-TCRδ or anti-IL-17A treatment impacted Lm colonization after primary infection. These results suggest that γδTCR signaling and IL-17A are dispensable for protection after primary foodborne Lm infection consistent with the role of conventional T cells during the early innate immune response to Lm.

CONCLUSIONS

Lm-elicited adaptive Vγ4 T cells appear resistant to immunosenescence and memory Vγ4 T cells could be utilized to provide protective immune functions during enteric infection of aged hosts. As such, oral immunization might offer an efficient therapeutic approach to generate unconventional memory T cells in the elderly.

Assessment of the Microbiological Quality and Safety of Unpasteurized Milk Cheese for Sale in England between 2019 and 2020

ABSTRACT

Cheese made with unpasteurized milk has been associated with outbreaks of illness. However, there are limited data on the prevalence of Shiga toxin-producing Escherichia coli (STEC) in these products and a lack of clarity over the significance of E. coli as a general indicator of hygiene in raw milk cheeses. The aim of this study was to provide further data to address both of these issues, as well as assessing the overall microbiological quality of raw milk cheeses available to consumers in England. A total of 629 samples of cheese were collected from retailers, catering premises, and manufacturers throughout England. The majority (80%) were made using cow's milk, with 14% made from sheep's milk and 5% from goat's milk. Samples were from 18 different countries of origin, with the majority originating from either the United Kingdom (40%) or France (35%). When interpreted against European Union microbiological criteria and United Kingdom guidance, 82% were considered to be of satisfactory microbiological quality, 5% were borderline, and 12% were unsatisfactory. Four samples (0.6%) were potentially injurious to health due to the isolation of STEC from one, >104 CFU/g of coagulase-positive staphylococci in two, and >100 CFU/g of Listeria monocytogenes in the fourth sample. Indicator E. coli and Listeria species were detected more frequently in soft compared with hard cheese. Higher levels of indicator E. coli were significantly associated with a greater likelihood of detecting Shiga toxin genes (stx1 and/or stx2).

HIGHLIGHTS

Molecular genotyping reveals inter-regional relatedness among antimicrobial resistant Salmonella Minnesota strains isolated from poultry farm and humans, Brazil

Genetic profiles of Salmonella Minnesota isolates were analyzed using pulsed-field gel electrophoresis (PFGE). In total, 13 isolates obtained from the broiler industry collected in the states of Minas Gerais (11) and São Paulo (2), as well as five recovered from cases of foodborne infections in humans in the states of Minas Gerais (2), Santa Catarina (1), and Rio Grande do Sul (2), were submitted to PFGE. These 18 S. Minnesota isolates together with other 12 of poultry origin were also subjected to antimicrobial susceptibility testing. The PFGE analysis of 18 strains of S. Minnesota generated a dendrogram that grouped the isolates with 83-90% similarity into four main clusters. Among them, cluster "A" grouped the majority of isolates (13), including two of human origin that showed 90% similarity with a broiler isolate, both recovered in Minas Gerais. The S. Minnesota isolates showed resistance to tetracycline (80%), cefoxitin (80%), ceftazidime (46.7%), nalidixic acid (23.3%), ciprofloxacin (13.3%), and streptomycin (10%). No resistance to gentamicin, chloramphenicol, meropenem, nitrofurantoin, and sulfamethoxazole-trimethoprim was found. Moreover, 23.3% of the evaluated isolates presented multi-resistance profile, all from Minas Gerais. The results highlight the importance of further studies involving S. Minnesota, which is prevalent in the Brazilian broiler flocks and could provoke foodborne infection in humans.

Presence of hepatitis E virus in commercially available pork products

An increasing number of hepatitis E virus (HEV) infections in industrialized countries have been foodborne and linked to the consumption of undercooked pork products. To date, data on the prevalence of HEV in pork products sold in the United States is limited and no standard processing method exists for the detection of HEV in foods. In order to develop a processing method for the detection of HEV in pork products, ground pork and pork liver were selected for method development. Murine norovirus (MNV) was used as a process control. A filtration step prior to RNA detection was shown to reduce the level of PCR inhibitors in ground pork and an additional ultracentrifugation process was successful in removing PCR inhibitors in pork liver. MNV RNA was detected in ground pork and liver samples inoculated with 4.7 log₁₀ PFU/g and 3.0 log₁₀ PFU/g, respectively. Using the developed method for viral RNA detection in ground pork and pork liver, 20 packages of ground pork (six 1 g sub-samples per package) and 14 pork livers (four 1 g sub-samples per liver) were screened for the presence of HEV RNA. Fifteen out of 119 (12.6%) ground pork samples tested positive for HEV RNA and 13 out of 20 packages (65%) contained at least one positive sample. Twenty-five of 56 (45%) of pork liver samples were positive for HEV RNA and 6 of 14 livers (43%) had all sub-samples test positive for HEV RNA. Overall, the results indicate ground pork and pig liver as a potential source of HEV.

An outbreak of human listeriosis associated with frozen sweet corn consumption: Investigations in the UK

The use of Whole genome sequencing (WGS) identified a multi-country outbreak of human listeriosis associated with consumption of frozen sweet corn produced in Hungary. The purpose of this report was to summarise information on the cases occurring in the UK which were part of this outbreak and outline investigations on the presence of Listeria monocytogenes in the affected food chain. Prior to the international recall of this product in 2018, 12 UK cases of listeriosis were identified as infected by the outbreak strain between 2015 and 18. Epidemiological and microbiological investigations confirmed these cases as belonging to the outbreak. A further case occurred in 2019 and a contaminated frozen pack from one of the implicated batches of sweet corn was recovered from the patient's domestic freezer. The outbreak strain was also detected in products from a sandwich manufacturer in 2018 which added frozen sweet corn directly to sandwich fillings. The sandwich manufacturer's sweet corn was supplied by a distributor in England which obtained frozen products from the Hungarian manufacturer implicated in the outbreak. Within the distributor's premises, 208 food and environmental samples were taken: L. monocytogenes was detected in 44% of 70 samples of frozen sweet corn and 5% of 79 other foods. The outbreak strain was detected in the frozen sweet corn, in one other frozen food (mixed vegetables) and in the factory environment. The outbreak strain was also recovered from frozen beans on retail sale in the first four months of 2019. Five other L. monocytogenes strains together with two other Listeria species were detected in samples from the importer's premises. One of the L. monocytogenes strains in the importer's factory, which was distinct from the outbreak strain, was also recovered from sweet corn collected from the sandwich manufacturer, sweet corn tested in England in 2013 and 2016 and the blood of two cases of human listeriosis which occurred in England in 2014. This report shows how analysis by WGS provides evidence to understand complex food chains. This report also highlights risks for transmission of human listeriosis from frozen sweet corn and the potential for misuse of this food as a ready-to-eat product.

Zoonotic risks of pathogens from sheep and their milk borne transmission

Sheep were domesticated around 9000 BC in the Middle East, and since then milk from sheep gradually became very popular, not only for drinking but also for making cheeses and other dairy products. Nowadays, these dairy products are also important for people with an allergy to cow milk, and these products are an essential part of the local daily diet in regions of the world that are not suitable for cows and goats. Consumption of raw milk and raw milk products has a zoonotic risk, and with regard to sheep, the main pathogens associated with such dairy products are: Brucella melitensis, Campylobacter spp., Listeria spp., Salmonella spp., Shiga-toxin producing Escherichia coli, Staphylococcus aureus, tick borne encephalitis virus, and Toxoplasma gondii. Especially, young children, elderly people, pregnant women and immunocompromised (YOPI) persons, and those suffering from disease should be aware of the risk of consuming raw milk and raw milk products. This latter risk can be reduced by proper flock health management, prevention of contamination during milking, adequate milk processing, transport, and refrigerated storage. Only processes equaling pasteurization sufficiently reduce zoonotic risks from milk and milk products, but proper cooling is essential and recontamination must be prevented. Therefore, strict hygiene practices throughout the production process and supply chain especially for raw milk and raw dairy products, should be applied. Small scale production systems pose a greater risk compared to industrialized production systems because of a less protocolized and controlled production process. This manuscript describes zoonotic risks of pathogens from sheep and their milk borne transmission. Additionally, routes of contamination, possibilities for multiplication, and prevention measures thereof are described. We summarize some major human outbreaks caused by consumption of sheep milk and products made thereof, and finally discuss their implications.

Microbiological quality of raw drinking milk and unpasteurised dairy products: results from England 2013-2019

The aim of this study was to review microbiology results from testing >2500 raw drinking milk and dairy products made with unpasteurised milk examined in England between 2013 and 2019. Samples were collected as part of incidents of contamination, investigation of infections or as part of routine monitoring and were tested using standard methods for a range of both pathogens and hygiene indicators. Results from testing samples of raw cow's milk or cheese made from unpasteurised milk for routine monitoring purposes were overall of better microbiological quality than those collected during incident or investigations of infections. Results from routine monitoring were satisfactory for 62% of milks, 82% of cream, 100% of ice-cream, 51% of butter, 63% of kefir and 79% of cheeses, with 5% of all samples being considered potentially hazardous. Analysis of data from cheese demonstrated a significant association between increasing levels of indicator Escherichia coli with elevated levels of coagulase positive staphylococci and decreased probability of isolation of Shiga toxin-producing E. coli. These data highlight the public health risk associated with these products and provide further justification for controls applied to raw drinking milk and dairy products made with unpasteurised milk.

Swine hepatitis E virus: Cross-species infection, pork safety and chronic infection

Swine hepatitis E virus (swine HEV) belongs to the species Orthohepevirus A within the genus Orthohepevirus in the family Hepeviridae. Four different genotypes of swine HEV within the species Orthohepevirus A have been identified so far from domesticated and wild swine population: genotypes 3 (HEV-3) and 4 (HEV-4) swine HEVs are zoonotic and infect humans, whereas HEV-5 and HEV-6 are only identified from swine. As a zoonotic agent, swine HEV is an emerging public health concern in many industrialized countries. Pigs are natural reservoir for HEV, consumption of raw or undercooked pork is an important route of foodborne HEV transmission. Occupational risks such as direct contact with infected pigs also increase the risk of HEV transmission in humans. Cross-species infection of HEV-3 and HEV-4 have been documented under experimental and natural conditions. Both swine HEV-3 and swine HEV-4 infect non-human primates, the surrogates of man. Swine HEV, predominantly HEV-3, can establish chronic infection in immunocompromised patients especially in solid organ transplant recipients. The zoonotic HEV-3, and to lesser extent HEV-4, have also been shown to cause neurological diseases and kidney injury. In this review, we focus on the epidemiology of swine HEV, host and viral determinants influencing cross-species HEV infection, zoonotic infection and its associated pork safety concern, as well as swine HEV-associated chronic infection and neurological diseases.

An assessment of food safety information provision for UK chemotherapy patients to reduce the risk of foodborne infection

OBJECTIVES

Given the increased risk of foodborne infection to cancer patients receiving chemotherapy treatment, and the risk of listeriosis reportedly five-times greater to this immunocompromised patient group, there is a need to ensure the implementation of domestic food safety practices among chemotherapy patients and their family caregivers. However, information regarding the adequacy of resources to inform and enable patients to implement domestic food safety practices to reduce the risk of foodborne infection is limited. Consequently, this study aimed to evaluate the provision of food safety information available to UK chemotherapy patients.

STUDY DESIGN

In-depth semi-structured interviews and content analysis of online patient information resources.

METHODS

Interviews with patients and family caregivers (n = 15) were conducted to explore food-related experiences during chemotherapy treatment. Online food-related information resources for chemotherapy patients (n = 45) were obtained from 35 of 154 National Health Service chemotherapy providers in England, Scotland, and Wales, the Department of Health (DoH) and three of 184 identified UK cancer charities. Identified food-related information resources were reviewed using a content-analysis approach to assess the inclusion of food safety information for chemotherapy patients.

RESULTS

In-depth interviews established that many patients indicated awareness of immunosuppression during treatment. Although patients reported practicing caution to reduce the risk of communicable diseases by avoiding crowded spaces/public transport, food safety was reported to be of minimal concern during treatment and the risk of foodborne infection was often underestimated. The review of online food-related patient information resources established that many resources failed to highlight the increased risk of foodborne infection and emphasize the importance of food safety for patients during chemotherapy treatment. Considerable information gaps exist, particularly in relation to listeriosis prevention practices. Cumulatively, information was inconsistent, insufficient, and varied between resources.

CONCLUSION

The study has identified the need for an effective, standardized food safety resource specifically targeting chemotherapy patients and family caregivers. Such intervention is essential to assist efforts in reducing the risks associated with foodborne infection among chemotherapy patients.

Keeping it cool: Survival of Giardia cysts and Cryptosporidium oocysts on lettuce leaves

Fresh produce has been recognized as a vehicle for transmission of protozoan parasites for many years, and there are numerous publications regarding their occurrence on such foodstuffs, indicating their potential importance as foodborne parasites. Nevertheless, few studies have been published regarding the effectiveness of this transmission route, and whether contamination is likely to result in transmission. The purpose of this study was to assess the viability of Cryptosporidium oocysts and Giardia cysts, two protozoa associated with both waterborne and foodborne transmission, by spiking fresh produce (lettuce leaves) with viable transmission stages and determining changes in viability. These investigations were performed under different conditions and over time spans that may be used in a regular household; a fridge at 4°C, under ambient temperatures exposed to natural cycles of light during night and day, and inside a cupboard to ensure no light exposure, for a duration of up to two weeks, or as long as the produce remained visually palatable. The major finding from this study is that whereas both Cryptosporidium oocysts and Giardia cysts survive well when kept moist and refrigerated, survival of Giardia cysts was abrogated on lettuce at room temperature. Indeed, almost 50% die-off of Giardia cysts was recorded within the first 24h. Cryptosporidium oocysts had a stable viability throughout the experiment under all the conditions investigated, indicating that fresh produce is a suitable transmission vehicle for Cryptosporidium, even if contamination occurs on-farm and the parasites are exposed to non-favourable storage conditions, as may be common in developing countries. Giardia cysts were not as robust as Cryptosporidium oocysts, and would be probably unlikely to survive under ambient storage conditions on-farm, during sale, or at home. However, if kept refrigerated, then some contaminating Giardia cysts may remain viable and therefore may pose a threat to the consumer. Thus, as the cold chain for transport and storage of fresh produce improves, it is important that similar improvements are implemented to reduce the contamination of fresh produce with parasite transmission stages.

Risk factors and spatial distribution of extended spectrum β-lactamase-producing- Escherichia coli at retail poultry meat markets in Malaysia: a cross-sectional study

Background

The significant role of retail poultry meat as an important exposure pathway for the acquisition and transmission of extended spectrum β-lactamase-producing Escherichia coli (ESBL-EC) into the human population warrants understanding concerning those operational practices associated with dissemination of ESBL-EC in poultry meat retailing. Hence, the objective of this study was to determine the prevalence, spatial distribution and potential risk factors associated with the dissemination of ESBL-EC in poultry meat retail at wet-markets in Selangor, Malaysia.

Methods

Poultry meat (breast, wing, thigh, and keel) as well as the contact surfaces of weighing scales and cutting boards were sampled to detect ESBL-EC by using culture and disk combination methods and polymerase chain reaction assays. Besides, questionnaire was used to obtain data and information pertaining to those operational practices that may possibly explain the occurrence of ESBL-EC. The data were analysed using logistic regression analysis at 95 % CI.

Results

The overall prevalence of ESBL-EC was 48.8 % (95 % CI, 42 – 55 %). Among the risk factors that were explored, type of countertop, sanitation of the stall environment, source of cleaning water, and type of cutting board were found to be significantly associated with the presence of ESBL-EC.

Conclusions

Thus, in order to prevent or reduce the presence of ESBL-EC and other contaminants at the retail-outlet, there is a need to design a process control system based on the current prevailing practices in order to reduce cross contamination, as well as to improve food safety and consumer health.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3377-2) contains supplementary material, which is available to authorized users.

A rare but fatal water- and foodborne infection: Review of the literature and clinical cases from a single centre

BACKGROUND

Edwardsiella tarda bacteremia (ETB) can be a fatal disease in humans.

OBJECTIVES

To determine the significant risk factors associated with death caused by ETB, and to examine the geographical, seasonal, environmental and dietary factors of the disease.

METHODS

A retrospective, observational, case control study was performed. The PubMed MEDLINE and Japanese Medical Abstract Society (www.jamas.or.jp) databases were searched for ETB case reports and meeting abstracts. In additon, retrospective chart reviews of patients with ETB at the Tokyo Women's Medical University Hospital (Tokyo, Japan) were conducted to evaluate the risk factors associated with death using multivariate analyses.

RESULTS

The literature search yielded 46 publications, comprising 72 cases from the English (n=30), French (n=1), Spanish (n=1) and Japanese (n=14) literature. Five cases at the Tokyo Women's Medical University Hospital were also included. Of the included 77 cases, the mean age was 61 years and 39% of patients were female; 77.2% of the cases occurred between June and November, and 45.5% were reported in Japan. Dietary factors (raw fish/meat exposure) were reported for 10.4% of patients and 12.9% reported environmental (ie, brackish water) exposure. The overall mortality rate was 44.6%; however, this rate increased to 61.1% for ETB patients with soft tissue infections. Liver cirrhosis was determined to be an independent risk factor associated with death (OR 12.0 [95% CI 2.46 to 58.6]; P=0.00213) using multivariate analyses.

DISCUSSION

To our knowledge, the present analysis was the first and largest multi-language review of ETB. Clinical characteristics of ETB resemble those of Aeromonas, typhoid fever and Vibrio vulnificus infections, in addition to sharing similar risk factors.

CONCLUSION

ETB should be categorized as a severe food- and waterborne infection, which results in high mortality for patients with liver cirrhosis.