Gastric Helicobacter Infection Induces Iron Deficiency in the INS-GAS Mouse

There is increasing evidence from clinical and population studies for a role of H. pylori infection in the aetiology of iron deficiency. Rodent models of Helicobacter infection are helpful for investigating any causal links and mechanisms of iron deficiency in the host. The aim of this study was to investigate the effects of gastric Helicobacter infection on iron deficiency and host iron metabolism/transport gene expression in hypergastrinemic INS-GAS mice. INS-GAS mice were infected with Helicobacter felis for 3, 6 and 9 months. At post mortem, blood was taken for assessment of iron status and gastric mucosa for pathology, immunohistology and analysis of gene expression. Chronic Helicobacter infection of INS- GAS mice resulted in decreased serum iron, transferrin saturation and hypoferritinemia and increased Total iron binding capacity (TIBC). Decreased serum iron concentrations were associated with a concomitant reduction in the number of parietal cells, strengthening the association between hypochlorhydria and gastric Helicobacter-induced iron deficiency. Infection with H. felis for nine months was associated with decreased gastric expression of iron metabolism regulators hepcidin, Bmp4 and Bmp6 but increased expression of Ferroportin 1, the iron efflux protein, iron absorption genes such as Divalent metal transporter 1, Transferrin receptor 1 and also Lcn2 a siderophore-binding protein. The INS-GAS mouse is therefore a useful model for studying Helicobacter-induced iron deficiency. Furthermore, the marked changes in expression of gastric iron transporters following Helicobacter infection may be relevant to the more rapid development of carcinogenesis in the Helicobacter infected INS-GAS model.     

Survival of Gastric and Enterohepatic Helicobacter spp. in Water: Implications for Transmission

Part of the reason for rejecting aquatic environments as possible vectors for the transmission of Helicobacter pylori has been the preference of this microorganism to inhabit the human stomach and hence use a direct oral-oral route for transmission. On the other hand, most enteric bacterial pathogens are well known for being able to use water as an environmental reservoir. In this work, we have exposed 13 strains of seven different Helicobacter spp. (both gastric and enterohepatic) to water and tracked their survival by standard plating methods and membrane integrity assessment. The influence of different plating media and temperatures and the presence of light on recovery was also assessed. There was good correlation between cultivability and membrane integrity results (Pearson's correlation coefficient = 0.916), confirming that the culture method could reliably estimate differences in survival among different Helicobacter spp. The species that survived the longest in water was H. pylori (>96 h in the dark at 25°C), whereas H. felis appeared to be the most sensitive to water (<6 h). A hierarchical cluster analysis demonstrated that there was no relationship between the enterohepatic nature of Helicobacter spp. and an increased time of survival in water. This work assesses for the first time the survival of multiple Helicobacter spp., such has H. mustelae, H. muridarum, H. felis, H. canadensis, H. pullorum, and H. canis, in water under several conditions and concludes that the roles of water in transmission between hosts are likely to be similar for all these species, whether enterohepatic or not.     

Prevalence of Helicobacter in Laboratory Micein Thailand

Prevalence of Helicobacter is mostly unknown in laboratory animals in Thailand. The 221 mice feces/cecum from 8 universities, 2 pharmaceutical companies and 3 research institutions in Thailand were surveyed for the prevalence and distribution of Helicobacter species by using the Electrochemical DNA chip. Helicobacter were detected 23/46 samples in Specific Pathogen Free (SPF) and 168/175 in conventional condition. Prevalence of Helicobacter were 98%, 96%, 92% and 78% in South (n=40), Northeast (n=40), North (n=25) and Central area (n=116), respectively. Only Central area holds SPF facility resulting in Helicobacter prevalence that seems to be lower than other areas. Three species of Helicobacter were detected in feces/cecum samples by sequence analysis: H. rodentium (67.0%, 148 samples), Helicobacter sp. MIT 01-6451 (15.4%, 34 samples), and unidentified Helicobacter species (14.1%, 9 samples). The results suggested that H. rodentium is the most common species of Helicobacter in laboratory mice in Thailand.     

Discrimination of Helicobacter pullorum and Campylobacter lari by analysis of whole cell fatty acid extracts

Helicobacter pullorum and Campylobacter lari are rarely isolated from humans with acute enteritis. Hitherto the two species could only be identified by genotypic techniques. Gas liquid chromatography of whole cell fatty acid extracts is described as the first phenotypic method for discrimination of the two species. Cholesteryl glucoside, a characteristic feature of the genus Helicobacter, but seldom found in other bacteria, could not be detected in Helicobacter pullorum. Therefore, rapid determination of this glycolipid may serve as a discrimination marker for Helicobacter pullorum from most other Helicobacter species.     

Use of the Common Marmoset to Study Burkholderia mallei Infection

Burkholderia mallei is a host-adapted bacterium that does not persist outside of its equine reservoir. The organism causes the zoonosis glanders, which is endemic in Asia, Africa, the Middle East and South America. Infection by B. mallei typically occurs via the respiratory or percutaneous route, and the most common manifestations are life-threatening pneumonia and bacteremia. Glanders is difficult to diagnose and requires prolonged antibiotic therapy with low success rates. There is no vaccine to protect against B. mallei and there is concern regarding its use as a biothreat agent. Thus, experiments were performed to establish a non-human primate model of intranasal infection to study the organism and develop countermeasures. Groups of marmosets (Callithrix jacchus) were inoculated intranasally with B. mallei strain ATCC 23344 and monitored for clinical signs of illness for up to 13 days. We discovered that 83% of marmosets inoculated with doses of 2.5 X 10⁴ to 2.5 X 10⁵ bacteria developed acute lethal infection within 3–4 days. Signs of disease were severe and included lethargy, inappetence, conjunctivitis, mucopurulent and hemorrhagic nasal discharges, and increased respiratory effort with abdominal lifts. Burkholderia mallei was cultured from the lungs, spleen and liver of these animals, and pathologic examination of tissues revealed lesions characteristic of glanders. Challenge experiments also revealed that 91% of animals infected with doses ranging from 25 to 2.5 X 10³ bacteria exhibited mild non-specific signs of illness and were culture negative. One marmoset inoculated with 2.5 X 10³ organisms developed moderate signs of disease and reached humane end-points 8 days post-infection. The liver and spleen of this animal were colonized with the agent and pathological analysis of tissues showed nasal, splenic and hepatic lesions. Taken together, these data indicate that the marmoset is a suitable model to study respiratory infection by B. mallei.     

Recomendaciones GEMICOMED/GEIRAS-SEIMC para el manejo de las infecciones y colonizaciones por Candida auris

Candida auris is a new species of Candida that causes nosocomial outbreaks in several countries around the world, including Spain. C. auris is resistant to fluconazole and multi- and pan-resistant strains have been described. It is highly transmissible and can survive long term in the hospital environment, causing long-lasting outbreaks that are difficult to detect in early stages, and making it difficult to control and eradicate. It is currently an emerging threat to global health.This document provides a set of guidelines, developed by a multidisciplinary team, to limit the impact and facilitate the control of C. auris infection based on the experiences gathered in the Spanish and English outbreaks. The implementation of early and strict surveillance and control measures is essential to prevent the spread of the outbreak, which can spread over time, posing a significant risk to complex, critical and immunocompromised surgical patients. Immediate notification of C. auris isolation to clinical and infection control teams, as well as to health authorities and institutions, is essential to implement infection control measures at all levels in a timely manner, to prevent internal and inter-centre transmission, and to ensure a proper surveillance and prevention to patients who are already colonized and can develop an infection.     

Constraints on the use of lifespan-shortening Wolbachia to control dengue fever

Dengue fever, a viral disease spread by the mosquito Aedes aegypti, affects 50–100 million people a year in many tropical countries. Because the virus must incubate within mosquito hosts for two weeks before being able to transmit the infection, shortening the lifespan of mosquitoes may curtail dengue transmission. We developed a continuous time reaction-diffusion model of the spatial spread of Wolbachia through a population of A. aegypti. This model incorporates the lifespan-shortening effects of Wolbachia on infected A. aegypti and the fitness advantage to infected females due to cytoplasmic incompatibility (CI). We found that local establishment of the Wolbachia infection can occur if the fitness advantage due to CI exceeds the fitness reduction due to lifespan-shortening effects, in accordance with earlier results concerning fecundity reduction. However, spatial spread is possible only if the fitness advantage due to CI is twice as great as the fitness reduction due to lifespan shortening effects. Moreover, lifespan-shortening and fecundity-reduction can have different effects on the speed of wave-retreat. Using data from the literature, we estimated all demographic parameters for infected and uninfected mosquitoes and computed the velocities of spread of infection. Our most optimistic estimates suggest that the spatial spread of lifespan-shortening Wolbachia may be so slow that efficient spatial spread would require a prohibitively large number of point releases. However, as these estimates of demographic parameters may not accurately reflect natural conditions, further research is necessary to corroborate these predictions.     

Helicobacter Infection Decreases Reproductive Performance of IL10-deficient Mice

Infections with a variety of Helicobacter species have been documented in rodent research facilities, with variable effects on rodent health. Helicobacter typhlonius has been reported to cause enteric disease in immunodeficient and IL10^−/− mice, whereas H. rodentium has only been reported to cause disease in immunodeficient mice coinfected with other Helicobacter species. The effect of Helicobacter infections on murine reproduction has not been well studied. The reproductive performance of C57BL/6 IL10^−/− female mice intentionally infected with H. typhlonius, H. rodentium, or both was compared with that of age-matched uninfected controls or similarly infected mice that received antihelicobacter therapy. The presence of Helicobacter organisms in stool and relevant tissues was detected by PCR assays. Helicobacter infection of IL10^−/− female mice markedly decreased pregnancy rates and pup survival. The number of pups surviving to weaning was greatest in noninfected mice and decreased for H. rodentium > H. typhlonius >> H. rodentium and H. typhlonius coinfected mice. Helicobacter organisms were detected by semiquantitative real-time PCR in the reproductive organs of a subset of infected mice. Treatment of infected mice with a 4-drug regimen consisting of amoxicillin, clarithromycin, metronidazole, and omeprazole increased pregnancy rates, and pup survival and dam fecundity improved. We conclude that infection with H. typhlonius, H. rodentium, or both decreased the reproductive performance of IL10^−/− mice. In addition, antihelicobacter therapy improved fecundity and enhanced pup survival.Abbreviations: qPCR, qualitative real-time PCRHelicobacter rodentium and H. typhlonius⁵ are gram-negative, urease-negative, microaerophilic flagellated bacteria.^6,20 Numerous Helicobacter species have been identified in various rodent organ systems, including portions of the gastrointestinal tract, liver, and associated biliary system.⁵ Although they often are found in the intestinal tract of immunocompetent mice without clinical disease, various Helicobacter species have been shown induce enteric disease in immunodeficient mice.^6,20 This propensity has been a useful tool in developing mouse models to study inflammatory bowel disease and colon cancer.^7,13,14Murine fecal samples submitted from a variety of institutions to the University of Missouri Research Animal Diagnostic Laboratory (Columbia, MO) between November 2001 and October 2002 showed 17% positivity for H. typhlonius and 10% positivity for H. rodentium.¹¹ H. typhlonius has been reported to cause significant enteric disease in immunodeficient and IL10^−/− mice.⁴ In contrast, H. rodentium has only been reported to cause disease in immunodeficient mice coinfected with other Helicobacter species.^16,20,21 Because these agents cause disease, they are best considered to be rodent pathogens, despite the frequency of their detection in clinically normal mice. Although most murine Helicobacter infections are subclinical, infection with H. rodentium and H. typhlonius may affect experimental studies in vivo under some circumstances. In addition, Helicobacter infections can influence murine reproduction, although this effect has not been well studied.The gastric-infecting species H. pylori influences murine pregnancy by increasing the number of fetal resorptions and producing lower fetal weights compared with those of noninfected controls.¹⁸ Induction of Th1-type responses at the endometrial level was a possible mechanism suggested for these phenomena but not further investigated. Whether intestinal-infecting Helicobacter species such as H. rodentium and H. typhlonius affect murine pregnancy in wild-type or genetically modified mice, particularly those with mutations that affect immune function, has not been determined.Mice deficient in IL10 (IL10^−/− mice) mount an exaggerated and prolonged inflammatory response resulting from their lack of circulating IL10, a cytokine that normally functions to limit inflammatory processes. Thus IL10^−/− mice may be at greater risk of adverse effects after Helicobacter infection due to their lack of IL10 to inhibit Th1 immune responses. In a breeding colony of IL10^−/− mice, those housed in a facility where H. rodentium or H. typhlonius (or both) infections were endemic appeared to have less reproductive success than those that were housed in a facility free from Helicobacter spp. These observations lead to this study to specifically determine the effect of infection with H. rodentium and H. typhlonius on the fecundity (potential reproductive capacity) of IL10^−/− mice. Because antihelicobacter drug therapy might provide a viable alternative to embryo rederivation for some strains, particularly relative to the risk and resource commitment involved with rederivation, we also investigated whether reproductive performance could be improved by the administration of commercially available antihelicobacter wafers as a method of Helicobacter eradication.     

Are Helicobacter Pylori and Other Helicobacter Species Infection Associated with Human Biliary Lithiasis? A Meta-Analysis

Background

Since the isolation of Helicobacter species in biliary system, a hypothetical question was raised about the role of these agents in the development of cholelithiasis. This meta-analysis is to explore the association between the Helicobacter infection and biliary lithiasis.

Methodology/Principal Findings

A systematic literature search was performed to identify all eligible articles. Meta-analysis which was carried out using odds ratio and random effect model, 95% confidence intervals for odds ratio was calculated. Quantitative assessment of heterogeneity was explored by chi-square test with significance set at P value 0.10 and was measured using I ² statistic. Eighteen studies published between 1998 and 2011 were finally eligible for meta-analysis. H. Pylori, H. Bilis, H. Hepaticus, H. Pullorum and H. Ganmani were studied. With heterogeneity (I² = 69.5%, P<0.0001), significantly higher pooled infection rates of H. Pylori (OR: 2.59, 35.82% versus 26.75%, P = 0.01) and H. Hepaticus (OR: 3.13, 31.30% versus 12.12%, P = 0.02) were observed in lithiasis group. Higher prevalence of H. Pylori in cholelithiasis patients were reported by studies from East Asia, South Asia and South America. Evidences supporting the higher presence of H. Pylori in cholelithiasis patients could be found by PCR for detecting 16s rRNA in bile, 26kDa protein gene in biliary tissue and immunohistochemistry. Using multiple detection tests could increase the detection rate of H. Pylori.

Conclusions/Significances

Our meta-analysis suggests a trend of higher presence of H. Pylori in cholelithiasis patients than control group and this trend was significant in the regions with higher prevalence of this agent. Evidences supporting the association between Helicobacter and cholelithiasis could be found by using different tests but the gold standard for the identification of these bacteria in biliary system has yet to be established. Considering obvious heterogeneity, a large multi-center study will facilitate us to further clarify the association between the Helicobacter infection and cholelithiasis.     

Helicobacter pylori sensitizes TNF-related apoptosis-inducing ligand (TRAIL)-mediated apoptosis in human gastric epithelial cells through regulation of FLIP

Helicobacter pylori (H. pylori) infection is associated with chronic gastritis, peptic ulcer and gastric cancer. Apoptosis induced by microbial infections is implicated in the pathogenesis of H. pylori infection. Here we show that human gastric epithelial cells sensitized to H. pylori confer susceptibility to TRAIL-mediated apoptosis via modulation of death receptor signaling. Human gastric epithelial cells are intrinsically resistant to TRAIL-mediated apoptosis. The induction of TRAIL sensitivity by H. pylori is dependent on the activation of caspase-8 and its downstream pathway. H. pylori induces caspase-8 activation via enhanced assembly of the TRAIL death-inducing signaling complex (DISC) through downregulation of cellular FLICE-inhibitory protein (FLIP). Overexpression of FLIP abolished the H. pylori-induced TRAIL sensitivity in human gastric epithelial cells. Our study thus demonstrates that H. pylori induces sensitivity to TRAIL apoptosis by regulation of FLIP and assembly of DISC, which initiates caspase activation, resulting in the breakdown of resistance to apoptosis, and provides insight into the pathogenesis of gastric damage in Helicobacter infection. Modulation of host apoptosis signaling by bacterial interaction adds a new dimension to the pathogenesis of Helicobacter.     

Evaluation of the Protective Immunity of a Novel Subunit Fusion Vaccine in a Murine Model of Systemic MRSA Infection

Staphylococcus aureus is a common commensal organism in humans and a major cause of bacteremia and hospital acquired infection. Because of the spread of strains resistant to antibiotics, these infections are becoming more difficult to treat. Therefore, exploration of anti-staphylococcal vaccines is currently a high priority. Iron surface determinant B (IsdB) is an iron-regulated cell wall-anchored surface protein of S. aureus. Alpha-toxin (Hla) is a secreted cytolytic pore-forming toxin. Previous studies reported that immunization with IsdB or Hla protected animals against S. aureus infection. To develop a broadly protective vaccine, we constructed chimeric vaccines based on IsdB and Hla. Immunization with the chimeric bivalent vaccine induced strong antibody and T cell responses. When the protective efficacy of the chimeric bivalent vaccine was compared to that of individual proteins in a murine model of systemic S. aureus infection, the bivalent vaccine showed a stronger protective immune response than the individual proteins (IsdB or Hla). Based on the results presented here, the chimeric bivalent vaccine affords higher levels of protection against S. aureus and has potential as a more effective candidate vaccine.     

Differentiation of non-pylori Helicobacter species based on PCR–restriction fragment length polymorphism of the 23S rRNA gene

Phenotypic identification of non-pylori Helicobacter species has always been problematic and time-consuming in comparison with many other bacteria. We developed a rapid two-step identification assay based on PCR–restriction fragment length polymorphism (PCR–RFLP) analysis of the 23S rRNA gene for differentiating between non-pylori Helicobacter species. A new genus-specific primer pair based on all available complete and partial 23S rRNA sequences of Helicobacter species was designed. In silico restriction analysis of variable regions of the 23S rRNA gene suggested SmaI and HindIII endonucleases would provide a good level of differentiation. Analysis of the obtained 23S rRNA RFLP patterns divided all Helicobacter study strains into three species groups (groups A–C) and 12 unique restriction patterns. Wolinella succinogenes also gave a unique pattern. Our proposed PCR–RFLP method was found to be as a valuable tool for routine identification of non-pylori Helicobacter species from human or animal samples.     

Helicobacter pylori Genomic Microevolution during Naturally Occurring Transmission between Adults

The human gastric pathogen Helicobacter pylori is usually acquired during childhood and, in the absence of treatment, chronic infection persists through most of the host''s life. However, the frequency and importance of H. pylori transmission between adults is underestimated. Here we sequenced the complete genomes of H. pylori strains that were transmitted between spouses and analysed the genomic changes. Similar to H. pylori from chronic infection, a significantly high proportion of the determined 31 SNPs and 10 recombinant DNA fragments affected genes of the hop family of outer membrane proteins, some of which are known to be adhesins. In addition, changes in a fucosyltransferase gene modified the LPS component of the bacterial cell surface, suggesting strong diversifying selection. In contrast, virulence factor genes were not affected by the genomic changes. We propose a model of the genomic changes that are associated with the transmission and adaptation of H. pylori to a new human host.     

Enterohepatic Helicobacter in Ulcerative Colitis: Potential Pathogenic Entities?

Background

Changes in bacterial populations termed “dysbiosis” are thought central to ulcerative colitis (UC) pathogenesis. In particular, the possibility that novel Helicobacter organisms play a role in human UC has been debated but not comprehensively investigated. The aim of this study was to develop a molecular approach to investigate the presence of Helicobacter organisms in adults with and without UC.

Methodology/Principal Findings

A dual molecular approach to detect Helicobacter was developed. Oligonucleotide probes against the genus Helicobacter were designed and optimised alongside a validation of published H. pylori probes. A comprehensive evaluation of Helicobacter genus and H. pylori PCR primers was also undertaken. The combined approach was then assessed in a range of gastrointestinal samples prior to assessment of a UC cohort. Archival colonic samples were available from 106 individuals for FISH analysis (57 with UC and 49 non-IBD controls). A further 118 individuals were collected prospectively for dual FISH and PCR analysis (86 UC and 32 non-IBD controls). An additional 27 non-IBD controls were available for PCR analysis. All Helicobacter PCR-positive samples were sequenced. The association between Helicobacter and each study group was statistically analysed using the Pearson Chi Squared 2 tailed test. Helicobacter genus PCR positivity was significantly higher in UC than controls (32 of 77 versus 11 of 59, p = 0.004). Sequence analysis indicated enterohepatic Helicobacter species prevalence was significantly higher in the UC group compared to the control group (30 of 77 versus 2 of 59, p<0.0001). PCR and FISH results were concordant in 74 (67.9%) of subjects. The majority of discordant results were attributable to a higher positivity rate with FISH than PCR.

Conclusions/Significance

Helicobacter organisms warrant consideration as potential pathogenic entities in UC. Isolation of these organisms from colonic tissue is needed to enable interrogation of pathogenicity against established criteria.     

Enterotoxigenicity and Genetic Relatedness of Clostridium perfringens Isolates from Retail Foods in the United States

Clostridium perfringens is a leading cause of bacterial food-borne illness in countries where consumption of meat and poultry is high. For example, each year in the United States, this organism is the second or third most common cause of confirmed cases of food-borne illness. Surveys of the incidence of this organism in retail foods were done in the 1960s without regard to whether isolates were enterotoxigenic. It is now known that not all strains of this organism possess the enterotoxin gene responsible for illness. We examined the incidence of this organism in 131 food samples from retail food stores in an area of the northeastern United States. Forty isolates were obtained by using the iron milk method at 45°C, with confirmation by use of motility nitrate and lactose gelatin media. The presence of the C. perfringens enterotoxin (cpe) and alpha toxin (cpa) genes was determined by PCR using previously published primer sequences. All isolates possessed cpa. None of the isolates were identified as carrying the cpe gene by this method or by another method using a digoxigenin-labeled gene probe. Consistent with these results, none of the sporulating-cell extracts contained enterotoxin as determined by reverse passive latex hemagglutination. Pulsed-field gel electrophoresis was used to determine the genetic relatedness of the isolates. About 5% of the isolates were considered to be closely related (2- to 3-band difference). The others were considered to be unrelated to one another. The results demonstrate the rarity of cpe⁺ strains in retail foods and the genetic diversity among nonoutbreak strains.     

Host and pathogen ecology drive the seasonal dynamics of a fungal disease,white-nose syndrome

Seasonal patterns in pathogen transmission can influence the impact of disease on populations and the speed of spatial spread. Increases in host contact rates or births drive seasonal epidemics in some systems, but other factors may occasionally override these influences. White-nose syndrome, caused by the emerging fungal pathogen Pseudogymnoascus destructans, is spreading across North America and threatens several bat species with extinction. We examined patterns and drivers of seasonal transmission of P. destructans by measuring infection prevalence and pathogen loads in six bat species at 30 sites across the eastern United States. Bats became transiently infected in autumn, and transmission spiked in early winter when bats began hibernating. Nearly all bats in six species became infected by late winter when infection intensity peaked. In summer, despite high contact rates and a birth pulse, most bats cleared infections and prevalence dropped to zero. These data suggest the dominant driver of seasonal transmission dynamics was a change in host physiology, specifically hibernation. Our study is the first, to the best of our knowledge, to describe the seasonality of transmission in this emerging wildlife disease. The timing of infection and fungal growth resulted in maximal population impacts, but only moderate rates of spatial spread.     

High Prevalence and Species Diversity of Helicobacter spp. Detected in Wild House Mice

PCR diagnostics detected 100% prevalence of Helicobacter in 425 wild house mice (Mus musculus) from across central Europe. Of seven species identified, the five most frequent were Helicobacter rodentium (78%), H. typhlonius (53%), H. hepaticus (41%), H. bilis (30%), and H. muridarum (1%). Double infections were more common (42%) than single (30%) and triple (21%) infections. Wild house mice could be considered potential reservoirs of Helicobacter strains for both humans and other vertebrates.     

Determinants of the Final Size and Case Rate of Nosocomial Outbreaks

Different nosocomial pathogen species have varying infectivity and durations of infectiousness, while the transmission route determines the contact rate between pathogens and susceptible patients. To determine if the pathogen species and transmission route affects the size and spread of outbreaks, we perform a meta-analysis that examines data from 933 outbreaks of hospital-acquired infection representing 14 pathogen species and 8 transmission routes. We find that the mean number of cases in an outbreak is best predicted by the pathogen species and the mean number of cases per day is best predicted by the species-transmission route combination. Our fitted model predicts the largest mean number of cases for Salmonella outbreaks (22.3) and the smallest mean number of cases for Streptococci outbreaks (8.5). The largest mean number of cases per day occurs during Salmonella outbreaks spread via the environment (0.33) and the smallest occurs for Legionella outbreaks spread by multiple transmission routes (0.005). When combined with information on the frequency of outbreaks these findings could inform the design of infection control policies in hospitals.