Genetic diversity and microevolution of Burkholderia pseudomallei in the environment

Background

The soil dwelling Gram-negative pathogen Burkholderia pseudomallei is the cause of melioidosis. The diversity and population structure of this organism in the environment is poorly defined.

Methods and Findings

We undertook a study of B. pseudomallei in soil sampled from 100 equally spaced points within 237.5 m² of disused land in northeast Thailand. B. pseudomallei was present on direct culture of 77/100 sampling points. Genotyping of 200 primary plate colonies from three independent sampling points was performed using a combination of pulsed field gel electrophoresis (PFGE) and multilocus sequence typing (MLST). Twelve PFGE types and nine sequence types (STs) were identified, the majority of which were present at only a single sampling point. Two sampling points contained four STs and the third point contained three STs. Although the distance between the three sampling points was low (7.6, 7.9, and 13.3 meters, respectively), only two STs were present in more than one sampling point. Each of the three samples was characterized by the localized expansion of a single B. pseudomallei clone (corresponding to STs 185, 163, and 93). Comparison of PFGE and MLST results demonstrated that two STs contained strains with variable PFGE banding pattern types, indicating geographic structuring even within a single MLST-defined clone.

Conclusions

We discuss the implications of this extreme structuring of genotype and genotypic frequency in terms of micro-evolutionary dynamics and ecology, and how our results may inform future sampling strategies.     

Population Structure of Clinical Pseudomonas aeruginosa from West and Central African Countries

Background

Pseudomonas aeruginosa (PA) has a non-clonal, epidemic population with a few widely distributed and frequently encountered sequence types (STs) called ‘high-risk clusters’. Clinical P. aeruginosa (clinPA) has been studied in all inhabited continents excepted in Africa, where a very few isolates have been analyzed. Here, we characterized a collection of clinPA isolates from four countries of West and Central Africa.

Methodology

184 non-redundant isolates of clinPA from hospitals of Senegal, Ivory Coast, Nigeria, and Central African Republic were genotyped by MLST. We assessed their resistance level to antibiotics by agar diffusion and identified the extended-spectrum β-lactamases (ESBLs) and metallo-β-lactamases (MBLs) by sequencing. The population structure of the species was determined by a nucleotide-based analysis of the entire PA MLST database and further localized on the phylogenetic tree (i) the sequence types (STs) of the present collection, (ii) the STs by continents, (iii) ESBL- and MBL-producing STs from the MLST database.

Principal Findings

We found 80 distinct STs, of which 24 had no relationship with any known STs. ‘High-risk’ international clonal complexes (CC155, CC244, CC235) were frequently found in West and Central Africa. The five VIM-2-producing isolates belonged to CC233 and CC244. GES-1 and GES-9 enzymes were produced by one CC235 and one ST1469 isolate, respectively. We showed the spread of ‘high-risk’ international clonal complexes, often described as multidrug-resistant on other continents, with a fully susceptible phenotype. The MBL- and ESBL-producing STs were scattered throughout the phylogenetic tree and our data suggest a poor association between a continent and a specific phylogroup.

Conclusions

ESBL- and MBL-encoding genes are borne by both successful international clonal complexes and distinct local STs in clinPA of West and Central Africa. Furthermore, our data suggest that the spread of a ST could be either due to its antibiotic resistance or to features independent from the resistance to antibiotics.     

Epidemiological relationships of <Emphasis Type="Italic">Campylobacter jejuni</Emphasis> strains isolated from humans and chickens in South Korea

Thirty-nine human isolates of Campylobacter jejuni obtained from a national university hospital during 2007–2010 and 38 chicken isolates of C. jejuni were collected from poultry farms during 2009–2010 in South Korea were used in this study. Campylobacter genomic species and virulence-associated genes were identified by PCR. Pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST) were performed to compare their genetic relationships. All isolates were highly resistant to ciprofloxacin, nalidixic acid, and tetracycline. Of all isolates tested, over 94% contained seven virulence associated genes (flaA, cadF, racR, dnaJ, cdtA, cdtB, and cdtC). All isolates were classified into 39 types by PFGE clustering with 90% similarity. Some chicken isolates were incorporated into some PFGE types of human isolates. MLST analysis for the 39 human isolates and 38 chicken isolates resulted in 14 and 23 sequence types (STs), respectively, of which 10 STs were new. STs overlapped in both chicken and human isolates included ST-21, ST-48, ST-50, ST-51, and ST-354, of which ST-21 was the predominant ST in both human and chicken isolates. Through combined analysis of PFGE types and STs, three chicken isolates were clonally related to the three human isolates associated with food poisoning (VII-ST-48, XXII-ST-354, and XXVIII-ST-51). They were derived from geographically same or distinct districts. Remarkably, clonal spread of food poisoning pathogens between animals and humans was confirmed by population genetic analysis. Consequently, contamination of campylobacters with quinolone resistance and potential virulence genes in poultry production and consumption may increase the risk of infections in humans.     

Genotypic Analysis of Klebsiella pneumoniae Isolates in a Beijing Hospital Reveals High Genetic Diversity and Clonal Population Structure of Drug-Resistant Isolates

Background

The genetic diversity and the clinical relevance of the drug-resistant Klebsiella pneumoniae isolates from hospital settings are largely unknown. We thus conducted this prospective study to analyze the molecular epidemiology of K. pneumoniae isolates from patients being treated in the 306 Hospital in Beijing, China for the period of November 1, 2010–October 31, 2011.

Methodology/Principal Findings

Antibiotic susceptibility testing, PCR amplification and sequencing of the drug resistance-associated genes, and multilocus sequence typing (MLST) were conducted. A total of 163 isolates were analyzed. The percentage of MDR, XDR and PDR isolates were 63.8% (104), 20.9 (34), and 1.8% (3), respectively. MLST results showed that 60 sequence types (STs) were identified, which were further separated by eBURST into 13 clonal complexes and 18 singletons. The most dominant ST was ST15 (10.4%). Seven new alleles and 24 new STs were first identified in this study. Multiple logistic regression analysis revealed that certain clinical characteristics were associated with those prevalent STs such as: from ICU, from medical ward, from community acquired infection, from patients without heart disease, from patients with treatment success, susceptible to extended spectrum cephalosporin, susceptible to cephamycins, susceptible to fluoroquinolones, and with MDR.

Conclusions/Significance

Our data indicate that certain drug-resistant K. pneumoniae clones are highly prevalent and are associated with certain clinical characteristics in hospital settings. Our study provides evidence demonstrating that intensive nosocomial infection control measures are urgently needed.     

Multilocus sequence typing of genital Chlamydia trachomatis in Norway reveals multiple new sequence types and a large genetic diversity

Background

The Chlamydia trachomatis incidence rate in Finnmark, the most northern and sparsely populated county in Norway, has been twice the national average. This population based cross-sectional study among Finnmark high school students had the following aims: i) to examine distribution of multilocus sequence types (STs) of C. trachomatis in a previously unmapped area, ii) to compare chlamydia genetic diversity in Finnmark with that of two urban regions, and iii) to compare discriminatory capacity of multilocus sequence typing (MLST) with conventional ompA sequencing in a large number of chlamydia specimens.

Methodology

ompA sequencing and a high-resolution MLST system based on PCR amplification and DNA sequencing of five highly variable genetic regions were used. Eighty chlamydia specimens from adolescents aged 15–20 years in Finnmark were collected in five high schools (n = 60) and from routine clinical samples in the laboratory (n = 20). These were compared to routine clinical samples from adolescents in Tromsø (n = 80) and Trondheim (n = 88), capitals of North and Central Norway, respectively.

Principal Findings

ompA sequencing detected 11 genotypes in 248 specimens from all three areas. MLST displayed 50 STs providing a five-fold higher resolution. Two-thirds of all STs were novel. The common ompA E/Bour genotype comprised 46% and resolved into 24 different STs. MLST identified the Swedish new variant of C. trachomatis not discriminated by ompA sequencing. Simpson''s discriminatory index (D) was 0.93 for MLST, while a corrected D_c was 0.97. There were no statistically significant differences in ST genetic diversity between geographic areas. Finnmark had an atypical genovar distribution with G being predominant. This was mainly due to expansion of specific STs of which the novel ST161 was unique for Finnmark.

Conclusions/Significance

MLST revealed multiple new STs and a larger genetic diversity in comparison to ompA sequencing and proved to be a useful tool in molecular epidemiology of chlamydia infections.     

Campylobacter Infection in Children in Malawi Is Common and Is Frequently Associated with Enteric Virus Co-Infections

Background

Campylobacter species are the most common cause of bacterial gastroenteritis in the developed world. However, comparatively few studies have determined the epidemiological features of campylobacteriosis in resource-poor settings.

Methods

A total of 1,941 faecal specimens collected from symptomatic (diarrhoeic) children and 507 specimens from asymptomatic (non-diarrhoeic) children hospitalised in Blantyre, Malawi, between 1997 and 2007, and previously tested for the presence of rotavirus and norovirus, was analysed for C. jejuni and C. coli using a real time PCR assay.

Results

Campylobacter species were detected in 415/1,941 (21%) of diarrhoeic children, with C. jejuni accounting for 85% of all cases. The median age of children with Campylobacter infection was 11 months (range 0.1–55 months), and was significantly higher than that for children with rotavirus and norovirus (6 months and 7 months respectively; P<0.001). Co-infection with either rotavirus or norovirus was noted in 41% of all cases in the diarrhoeic group. In contrast, the detection rate of Campylobacter in the non-diarrhoeic group was 14%, with viral co-infection identified in 16% of children with Campylobacter. There was no association between Campylobacter detection rate and season over the 10 year period.

Discussion

Using molecular detection methodology in hospitalised Malawian children, we have demonstrated a high prevalence of Campylobacter infection, with frequent viral co-infection. The burden of Campylobacter infection in young African children may be greater than previously recognised.     

Antimicrobial Susceptibility Profiles and Molecular Typing of Campylobacter jejuni and Campylobacter coli Isolates from Ducks in South Korea

Campylobacter is a food-borne zoonotic pathogen that causes human gastroenteritis worldwide. Campylobacter bacteria are commensal in the intestines of many food production animals, including ducks and chickens. The objective of the study was to determine the prevalence of Campylobacter species in domestic ducks, and the agar dilution method was used to determine resistance of the isolates to eight antibiotics. In addition, multilocus sequence typing (MLST) was performed to determine the sequence types (STs) of selected Campylobacter isolates. Between May and September 2012, 58 duck farms were analyzed, and 56 (96.6%) were positive for Campylobacter. Among the isolates, 82.1% were Campylobacter jejuni, 16.1% were C. coli, and one was unidentified by PCR. Of the 46 C. jejuni isolates, 87.0%, 10.9%, and 21.7% were resistant to ciprofloxacin, erythromycin, and azithromycin, respectively. Among the C. coli isolates, all 9 strains were resistant to ampicillin, and 77.8% and 33.3% were resistant to ciprofloxacin and azithromycin, respectively. The majority of the Campylobacter isolates were classified as multidrug resistant. Twenty-eight STs were identified, including 20 STs for C. jejuni and 8 STs for C. coli. The most common clonal complexes in C. jejuni were the ST-21 complex and the ST-45 complex, while the ST-828 complex predominated in C. coli. The majority of isolates were of STs noted in ducks and humans from earlier studies, along with seven STs previously associated only with human disease. These STs overlapped between duck and human isolates, indicating that Campylobacter isolates from ducks should be considered potential sources of human infection.     

A farm-level study of risk factors associated with the colonization of broiler flocks with <Emphasis Type="Italic">Campylobacter</Emphasis> spp. in Iceland, 2001 – 2004

Background  

Following increased rates of human campylobacteriosis in the late 1990's, and their apparent association with increased consumption of fresh chicken meat, a longitudinal study was conducted in Iceland to identify the means to decrease the frequency of broiler flock colonization with Campylobacter. Our objective in this study was to identify risk factors for flock colonization acting at the broiler farm level.     

The importance of climatic factors and outliers in predicting regional monthly campylobacteriosis risk in Georgia,USA

Incidence of Campylobacter infection exhibits a strong seasonal component and regional variations in temperate climate zones. Forecasting the risk of infection regionally may provide clues to identify sources of transmission affected by temperature and precipitation. The objectives of this study were to (1) assess temporal patterns and differences in campylobacteriosis risk among nine climatic divisions of Georgia, USA, (2) compare univariate forecasting models that analyze campylobacteriosis risk over time with those that incorporate temperature and/or precipitation, and (3) investigate alternatives to supposedly random walk series and non-random occurrences that could be outliers. Temporal patterns of campylobacteriosis risk in Georgia were visually and statistically assessed. Univariate and multivariable forecasting models were used to predict the risk of campylobacteriosis and the coefficient of determination (R ²) was used for evaluating training (1999–2007) and holdout (2008) samples. Statistical control charting and rolling holdout periods were investigated to better understand the effect of outliers and improve forecasts. State and division level campylobacteriosis risk exhibited seasonal patterns with peaks occurring between June and August, and there were significant associations between campylobacteriosis risk, precipitation, and temperature. State and combined division forecasts were better than divisions alone, and models that included climate variables were comparable to univariate models. While rolling holdout techniques did not improve predictive ability, control charting identified high-risk time periods that require further investigation. These findings are important in (1) determining how climatic factors affect environmental sources and reservoirs of Campylobacter spp. and (2) identifying regional spikes in the risk of human Campylobacter infection and their underlying causes.     

Identification and characterization of insect-specific proteins by genome data analysis

Background

Previous studies have sought to identify a link between the distribution of variable genes amongst isolates of Campylobacter jejuni and particular host preferences. The genomic sequence data available currently was obtained using only isolates from human or chicken hosts. In order to identify variable genes present in isolates from alternative host species, five subtractions between C. jejuni isolates from different sources (rabbit, cattle, wild bird) were carried out, designed to assess genomic variability within and between common multilocus sequence type (MLST) clonal complexes (ST-21, ST-42, ST-45 and ST-61).

Results

The vast majority (97%) of the 195 subtracted sequences identified had a best BLASTX match with a Campylobacter protein. However, there was considerable variation within and between the four clonal complexes included in the subtractions. The distributions of eight variable sequences, including four with putative roles in the use of alternative terminal electron acceptors, amongst a panel of C. jejuni isolates representing diverse sources and STs, were determined.

Conclusion

There was a clear correlation between clonal complex and the distribution of the metabolic genes. In contrast, there was no evidence to support the hypothesis that the distribution of such genes may be related to host preference. The other variable genes studied were also generally distributed according to MLST type. Thus, we found little evidence for widespread horizontal gene transfer between clonal complexes involving these genes.     

Campylobacteriosis in Urban versus Rural Areas: A Case-Case Study Integrated with Molecular Typing to Validate Risk Factors and to Attribute Sources of Infection

Campylobacter infection is a leading cause of bacterial gastroenteritis worldwide, and most clinical cases appear as isolated, sporadic infections for which the source is rarely apparent. From July 2005 to December 2007 we conducted a prospective case-case study of sporadic, domestically-acquired Campylobacter enteritis in rural versus urban areas and a prevalence study of Campylobacter in animal and environmental sources in the Eastern Townships, Quebec. Isolates were typed using Multilocus Sequence Typing (MLST) to reinforce the case-case findings and to assign a source probability estimate for each human isolate. The risk of human campylobacteriosis was 1.89-fold higher in rural than urban areas. Unconditional multivariate logistic regression analysis identified two independent risk factors associated with human Campylobacter infections acquired in rural area: occupational exposure to animals (OR = 10.6, 95% CI: 1.2–91, p = 0.032), and household water coming from a private well (OR = 8.3, 95% CI: 3.4–20.4, p<0.0001). A total of 851 C. jejuni isolates (178 human, 257 chicken, 87 bovine, 266 water, 63 wild bird) were typed using MLST. Among human isolates, the incidence rates of clonal complexes (CC) CC-21, CC-45, and CC-61 were higher in rural than urban areas. MLST-based source attribution analysis indicated that 64.5% of human C. jejuni isolates were attributable to chicken, followed by cattle (25.8%), water (7.4%), and wild birds (2.3%). Chicken was the attributable source for the majority of cases, independent of residential area, sex and age. The increased incidence in rural compared to urban areas was associated with occupational exposure to animals, particularly cattle among those aged 15–34 years, and with consumption of private well water. Both bovine and water exposure appeared to contribute to the seasonal variation in campylobacteriosis. These results provide a basis for developing public education and preventive programs targeting the risk factors identified.     

Population Genetics of Streptococcus dysgalactiae Subspecies equisimilis Reveals Widely Dispersed Clones and Extensive Recombination

Background

Streptococcus dysgalactiae subspecies equisimilis (SDSE) is an emerging global pathogen that can colonize and infect humans. Although most SDSE isolates possess the Lancefield group G carbohydrate, a significant minority have the group C carbohydrate. Isolates are further sub-typed on the basis of differences within the emm gene. To gain a better understanding of their molecular epidemiology and evolutionary relationships, multilocus sequence typing (MLST) analysis was performed on SDSE isolates collected from Australia, Europe and North America.

Methodology/Principal Findings

The 178 SDSE isolates, representing 37 emm types, segregate into 80 distinct sequence types (STs) that form 17 clonal complexes (CCs). Eight STs recovered from all three continents account for >50% of the isolates. Thus, a small number of STs are highly prevalent and have a wide geographic distribution. Both ST and CC strongly correlate with group carbohydrate. In contrast, eleven STs were associated with >1 emm type, suggestive of recombinational replacements involving the emm gene; furthermore, 35% of the emm types are associated with genetically distant STs. Data also reveal a history of extensive inter- and intra-species recombination involving the housekeeping genes used for MLST. Sequence analysis of single locus variants identified through goeBURST indicates that genetic change mediated by recombination occurred ∼4.4 times more frequently than by point mutation.

Conclusions/Significance

A few genetic lineages with an intercontinental distribution dominate among SDSE causing infections in humans. The distinction between group C and G isolates reflects recent evolution, and no long-term genetic isolation between them was found. Lateral gene transfer and recombination involving housekeeping genes and the emm gene are important mechanisms driving genetic variability in the SDSE population.     

Campylobacter spp. Recovered from the Upper Oconee River Watershed, Georgia in a 4-Year Study

Waterways should be considered in the migration routes of Campylobacter, and the genus has been isolated from several water sources. Inferences on migration routes can be made from tracking genetic types in populations found in specific habitats and testing how they are linked to other types. Water samples were taken over a 4-year period from waterways in the Upper Oconee River Watershed, Georgia, to recover isolates of thermophilic Campylobacter. The isolates were typed by multilocus sequence typing (MLST) and analyzed to determine the overall diversity of Campylobacter in that environment. Forty-seven independent isolates were recovered from 560 samples (8.4 %). Two (~4 %) isolates were Campylobacter coli, three (~6 %) isolates were putatively identified as Campylobacter lari, and the remaining 42 (~90 %) were Campylobacter jejuni. The C. jejuni and C. coli isolates were typed by the Oxford MLST scheme. Thirty sequence types (STs) were identified including 13 STs that were not found before in the MLST database, including 24 novel alleles. Of the 17 previously described STs, 10 have been isolated from humans, 6 from environmental water, and 6 from wild birds (five types from multiple sources). Seven sites had multiple positive samples, and on two occasions, the same ST was isolated at the same site. The most common type was STST61 with four isolates, and the most common clonal complex was CC179 with nine isolates. CC179 has been commonly associated with environmental water. Although some Campylobacter STs that were found in the Oconee River engage in widespread migration, most are tightly associated with or unique to environmental water sources.     

Genotype and Antibiotic Resistance Analyses of Campylobacter Isolates from Ceca and Carcasses of Slaughtered Broiler Flocks

To obtain genetic information about Campylobacter jejuni and Campylobacter coli from broilers and carcasses at slaughterhouses, we analyzed and compared 340 isolates that were collected in 2008 from the cecum right after slaughter or from the neck skin after processing. We performed rpoB sequence-based identification, multilocus sequence typing (MLST), and flaB sequence-based typing; we additionally analyzed mutations within the 23S rRNA and gyrA genes that confer resistance to macrolide and quinolone antibiotics, respectively. The rpoB-based identification resulted in a distribution of 72.0% C. jejuni and 28.0% C. coli. The MLST analysis revealed that there were 59 known sequence types (STs) and 6 newly defined STs. Most of the STs were grouped into 4 clonal complexes (CC) that are typical for poultry (CC21, CC45, CC257, and CC828), and these represented 61.8% of all of the investigated isolates. The analysis of 95 isolates from the cecum and from the corresponding carcass neck skin covered 44 different STs, and 54.7% of the pairs had matching genotypes. The data indicate that cross-contamination from various sources during slaughter may occur, although the majority of Campylobacter contamination on carcasses appeared to originate from the slaughtered flock itself. Mutations in the 23S rRNA gene were found in 3.1% of C. coli isolates, although no mutations were found in C. jejuni isolates. Mutations in the gyrA gene were observed in 18.9% of C. jejuni and 26.8% of C. coli isolates, which included two C. coli strains that carried mutations conferring resistance to both classes of antibiotics. A relationship between specific genotypes and antibiotic resistance/susceptibility was observed.Campylobacteriosis is the leading food-borne bacterial gastroenteritis worldwide (12, 15). In Switzerland, the number of registered campylobacteriosis cases has rapidly increased to more than 100 per 100,000 inhabitants in the past few years (14), and this trend has also been observed in the European Union (EU) (12). However, the real number of cases is likely higher, because not all cases are reported due to the self-limiting nature of the disease and its potentially mild symptoms.Campylobacter jejuni and Campylobacter coli are commonly associated with human infection, and they can be detected in up to 85% and 15% of cases, respectively (33). Despite the important role that C. jejuni and C. coli play as zoonotic pathogens worldwide, there is little information regarding the route(s) of transmission (17). Numerous case-control and modeling studies on the infection sources of C. jejuni and C. coli have suggested that handling and consumption of contaminated poultry meat are associated with a risk of human campylobacteriosis (17, 45, 47, 49, 51). Initial meat contamination with C. jejuni or C. coli from the chicken intestine may occur during commonly used automated slaughter processing through several routes, such as the air, water, previously slaughtered flocks, or machinery (19, 36, 37).Precise genotyping and continuous comparison of the strains obtained from, e.g., the production site, flocks, slaughterhouse, retail meat, and infected humans would help to trace the source of infection and might indicate possible intervention strategies for the contaminated site.DNA sequence-based typing methods, such as multilocus sequence typing (MLST), are well suited for this purpose (28), and MLST has become the method of choice for genotyping of Campylobacter (6, 8). Moreover, extension of the classical MLST technique for C. jejuni and C. coli with sequencing of the short variable region (SVR) within the flagellin-encoding gene flaB allows a more precise differentiation among strains that have the same MLST sequence type (ST) (9, 29). An extended MLST work flow was recently developed that reduces the associated time and cost (24). In addition, the new approach allows genetic determination of antibiotic resistance to quinolones and macrolides. Resistance to these antibiotics is a worldwide issue of concern, as an increasing number of Campylobacter isolates are resistant to them. Strikingly, a number of strains are resistant to ciprofloxacin (a quinolone) and, to a lesser extent, erythromycin (a macrolide), which is problematic, because these drugs are typically used to treat campylobacteriosis. Resistance to quinolones is mainly associated with a point mutation in the DNA gyrase gene (gyrA) at position C257T, and a transition in the 23S rRNA gene at position A2075G is commonly responsible for macrolide resistance (1). Simple sequence-based analysis of these common mutational positions can therefore provide information about the antibiotic susceptibility or resistance of a strain. Besides the prudent use of antibiotics, knowledge about the genetic composition of the infectious agent can be helpful to both treat the disease and prevent the spread of resistant strains.In the current study, MLST, flaB typing, and sequence-based determination of quinolone and macrolide resistances were used to investigate the genetic background of C. jejuni and C. coli isolates collected from Swiss broilers in a spatiotemporal study in 2008. We addressed the following three aspects: (i) the diversity of Campylobacter isolates that were recovered from pooled cecum samples and the carcass neck skin, (ii) the possible impact of cross- and self-contamination during slaughter, and (iii) the antibiotic resistance of Campylobacter strains from the broiler flocks and chicken carcasses. All of the data, including the strain information and trace files, were entered into a commercial Web-based Campylobacter MLST database (SmartGene, Zug, Switzerland). This database allows users to retrieve and compare information for any analyzed strain for monitoring purposes (24).     

Practicalities of Using Non-Local or Non-Recent Multilocus Sequence Typing Data for Source Attribution in Space and Time of Human Campylobacteriosis

In this study, 1208 Campylobacter jejuni and C. coli isolates from humans and 400 isolates from chicken, collected in two separate periods over 12 years in The Netherlands, were typed using multilocus sequence typing (MLST). Statistical evidence was found for a shift of ST frequencies in human isolates over time. The human MLST data were also compared to published data from other countries to determine geographical variation. Because only MLST typed data from chicken, taken from the same time point and spatial location, were available in addition to the human data, MLST datasets for other Campylobacter reservoirs from selected countries were used. The selection was based on the degree of similarity of the human isolates between countries. The main aim of this study was to better understand the consequences of using non-local or non-recent MLST data for attributing domestically acquired human Campylobacter infections to specific sources of origin when applying the asymmetric island model for source attribution. In addition, a power-analysis was done to find the minimum number of source isolates needed to perform source attribution using an asymmetric island model. This study showed that using source data from other countries can have a significant biasing effect on the attribution results so it is important to carefully select data if the available local data lack in quality and/or quantity. Methods aimed at reducing this bias were proposed.     

Characterisation of Clostridium difficile Hospital Ward–Based Transmission Using Extensive Epidemiological Data and Molecular Typing

Background

Clostridium difficile infection (CDI) is a leading cause of antibiotic-associated diarrhoea and is endemic in hospitals, hindering the identification of sources and routes of transmission based on shared time and space alone. This may compromise rational control despite costly prevention strategies. This study aimed to investigate ward-based transmission of C. difficile, by subdividing outbreaks into distinct lineages defined by multi-locus sequence typing (MLST).

Methods and Findings

All C. difficile toxin enzyme-immunoassay-positive and culture-positive samples over 2.5 y from a geographically defined population of ∼600,000 persons underwent MLST. Sequence types (STs) were combined with admission and ward movement data from an integrated comprehensive healthcare system incorporating three hospitals (1,700 beds) providing all acute care for the defined geographical population. Networks of cases and potential transmission events were constructed for each ST. Potential infection sources for each case and transmission timescales were defined by prior ward-based contact with other cases sharing the same ST. From 1 September 2007 to 31 March 2010, there were means of 102 tests and 9.4 CDIs per 10,000 overnight stays in inpatients, and 238 tests and 15.7 CDIs per month in outpatients/primary care. In total, 1,276 C. difficile isolates of 69 STs were studied. From MLST, no more than 25% of cases could be linked to a potential ward-based inpatient source, ranging from 37% in renal/transplant, 29% in haematology/oncology, and 28% in acute/elderly medicine to 6% in specialist surgery. Most of the putative transmissions identified occurred shortly (≤1 wk) after the onset of symptoms (141/218, 65%), with few >8 wk (21/218, 10%). Most incubation periods were ≤4 wk (132/218, 61%), with few >12 wk (28/218, 13%). Allowing for persistent ward contamination following ward discharge of a CDI case did not increase the proportion of linked cases after allowing for random meeting of matched controls.

Conclusions

In an endemic setting with well-implemented infection control measures, ward-based contact with symptomatic enzyme-immunoassay-positive patients cannot account for most new CDI cases. Please see later in the article for the Editors'' Summary     

Decreasing Trend of Overlapping Multilocus Sequence Types between Human and Chicken Campylobacter jejuni Isolates over a Decade in Finland

We describe the long-term multilocus sequence typing (MLST) analysis of the population structure and dynamics of 454 Finnish human Campylobacter jejuni isolates, as well as 208 chicken isolates, collected during the mid-1990s to 2007. The sequence type clonal complexes (ST CC) ST-45 CC, ST-21 CC, and ST-677 CC were the most common ones found among all isolates, and they covered 73.9% of all isolates. The ST-283 CC also was found frequently among chicken isolates (8.2%). The predominant STs among all isolates were ST-45, ST-50, and ST-677. ST-137 and ST-230 were common among human isolates, and ST-267 was found more frequently among chicken isolates than human isolates. The ST-45 CC was significantly associated with chicken isolates (P < 0.01), whereas the ST-21 CC was associated with human isolates (P < 0.001). The ST-677 CC was not associated with any host (P = 0.5), and an opposite temporary trend of this complex was seen among chicken and human isolates, with an increase in the former and a decrease in the latter during the study period. Furthermore, the ST-22 and ST-48 CCs were significantly associated with human isolates (P < 0.01), but neither of the CCs was found in chicken isolates. The annual overlap between STs from human and chicken isolates decreased from 76% at the beginning of the study to 58% at the end. Our results suggest that the importance of chicken as a reservoir for strains associated with human infections has declined despite the consumption of domestic chicken meat increasing during the follow-up period by 83%.Campylobacter jejuni is the most common bacterial cause of gastroenteritis worldwide. In Finland, registered human Campylobacter infections have increased from 2,629 cases in 1996 to 4,107 cases in 2007 (http://www3.ktl.fi/stat/). Of the 4,107 cases in 2007, 45% were registered in the Helsinki-Uusimaa region, where the annual incidence was highest (122/100,000; the national average is 78/100,000) as well. Most of the cases were associated with traveling to other countries. In 2007, approximately 57% of the patients had traveled outside of Finland prior to their illness, 19% had not traveled abroad, and for 24% information was unavailable (http://www.ktl.fi/attachments/suomi/julkaisut/julkaisusarja_b/2008/2008b09.pdf).In Finland, most of the Campylobacter infections are sporadic and appear during the summer months (http://www.efsa.europa.eu/en/scdocs/doc/130r.pdf). Between 1996 and 2007, approximately 45 to 55% of all registered infections were reported between June and September (http://www3.ktl.fi/stat/). In contrast to sporadic Campylobacter infections, outbreaks of campylobacteriosis are uncommon, usually occurring in spring or autumn, and are associated with drinking contaminated water (36).Epidemiological studies performed in many countries indicate that handling or eating chicken meat is an important risk factor for the acquisition of campylobacteriosis (32, 46). A recent Finnish case-control study (39) identified swimming in lakes and rivers and drinking water from private wells as additional risk factors for acquiring the illness from domestic sources during the summer months. Contact with pets (19) and farm animals (21) and the consumption of raw milk (35) also have been identified as risk factors for Campylobacter infections.The annual consumption of chicken meat in Finland increased by 83% (from 53 million to 95 million kg) from 1997 to 2007 but remained stable, at around 83.5 million kg, between 2002 and 2006. However, from 2006 to 2007, the consumption of chicken meat increased by a further 8% (from 88 million to 95 million kg). Most of the chicken meat consumed in Finland comes from domestic production (https://portal.mtt.fi/portal/page/portal/mtt/mtt/julkaisut/suomenmaatalousjamaaseutuelinkeinot/jul108_SM2008.pdf). Finnish chicken flocks have been monitored for Campylobacter spp. according to the regulations of the European Union since 2004 (http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2003:325:0031:0040:EN:PDF). Seasonality similar to that observed in human infections can be found in the prevalence of Campylobacter-positive chicken slaughter batches, i.e., 7.7% of all chicken slaughter batches were Campylobacter positive from June to October in 2007; however, during the rest of the year no positive chicken flocks were detected (http://www.efsa.europa.eu/en/scdocs/doc/130r.pdf).To assess the relevance of a particular source and potential routes of transmission from animals to humans (6), the overlap between genotypes of Campylobacter isolates from patients and potential sources of infection has been studied using molecular typing techniques such as pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST). Of the two typing methods, PFGE is more discriminatory and therefore is considered more suitable for short-term epidemiological investigations and for the determination of the source of infection in outbreak situations (24, 26, 28).In our previous studies, we have shown that during a seasonal peak, overlapping serotypes and PFGE genotypes exist between samples from patients suffering from campylobacteriosis and fecal samples from chicken (13, 17). Several other studies also have reported a 34 to 60% overlap between serotypes, genotypes, and/or sequence types (STs) of patient and poultry isolates using various typing techniques (20, 31, 37, 42).Due to the high diversity of types and the lack of standardized nomenclature, PFGE is not a useful technique in long-term epidemiological studies. Unlike PFGE, MLST has been successfully used in long-term epidemiological studies (27, 45) and in deciphering the population structure (2, 20, 28, 45) of Campylobacter on a global scale. MLST has high discriminatory power (23) and standardized nomenclature for STs and clonal complexes (CCs) (3, 26).The aim of our study was to analyze by MLST the overlap and dynamics of C. jejuni types among isolates collected from domestically acquired sporadic human infections from the Helsinki-Uusimaa region from 1996 to 2006 and isolates collected from domestic chicken production from 1999 to 2007.     

Binary IS typing for Staphylococcus aureus

Background

We present an easily applicable test for rapid binary typing of Staphylococcus aureus: binary interspace (IS) typing. This test is a further development of a previously described molecular typing technique that is based on length polymorphisms of the 16S-23S rDNA interspace region of S. aureus.

Methodology/Principal Findings

A novel approach of IS-typing was performed in which binary profiles are created. 424 human and animal derived MRSA and MSSA isolates were tested and a subset of these isolates was compared with multi locus sequence typing (MLST) and Amplified Fragment Length Polymorphism (AFLP). Binary IS typing had a high discriminatory potential and a good correlation with MLST and AFLP.

Conclusions/Significance

Binary IS typing is easy to perform and binary profiles can be generated in a standardized fashion. These two features, combined with the high correlation with MLST clonal complexes, make the technique applicable for large-scale inter-laboratory molecular epidemiological comparisons.     

Outbreak of Multi-Drug Resistant Pseudomonas aeruginosa Bloodstream Infection in the Haematology Unit of a South African Academic Hospital

Objective

To describe an outbreak of multi-resistant Pseudomonas aeruginosa bloodstream infections (MRPA-BSI) that occurred in the haematology ward of a tertiary academic hospital in Cape Town, South Africa, and determine risk factors for acquisition of MRPA-BSI.

Methods

The outbreak investigation included a search for additional cases, review of patient records, environmental and staff screening, molecular typing using pulsed-field gel electrophoresis (PFGE) and Multi-locus sequencing (MLST) and a retrospective case-control study.

Results

Ten MRPA-BSI cases occurred in the haematology ward between January 2010 and January 2011. The case fatality rate was 80%. Staff screening specimens were negative for MRPA and an environmental source was not identified. PFGE showed that 9/10 isolates were related. MLST showed that 3 of these 9 isolates belonged to Sequence type (ST) 233 while the unrelated isolate belonged to ST260.

Conclusion

We have described an outbreak of MRPA-BSI occurring over an extended period of time among neutropenic haematology patients. Molecular typing confirms that the outbreak was predominantly due to a single strain. The source of the outbreak was not identified, but the outbreak appears to have been controlled following intensive infection control measures.     

Rapid Quantification of Viable Campylobacter Bacteria on Chicken Carcasses,Using Real-Time PCR and Propidium Monoazide Treatment,as a Tool for Quantitative Risk Assessment

A number of intervention strategies against Campylobacter-contaminated poultry focus on postslaughter reduction of the number of cells, emphasizing the need for rapid and reliable quantitative detection of only viable Campylobacter bacteria. We present a new and rapid quantitative approach to the enumeration of food-borne Campylobacter bacteria that combines real-time quantitative PCR (Q-PCR) with simple propidium monoazide (PMA) sample treatment. In less than 3 h, this method generates a signal from only viable and viable but nonculturable (VBNC) Campylobacter bacteria with an intact membrane. The method''s performance was evaluated by assessing the contributions to variability by individual chicken carcass rinse matrices, species of Campylobacter, and differences in efficiency of DNA extraction with differing cell inputs. The method was compared with culture-based enumeration on 50 naturally infected chickens. The cell contents correlated with cycle threshold (C_T) values (R² = 0.993), with a quantification range of 1 × 10² to 1 × 10⁷ CFU/ml. The correlation between the Campylobacter counts obtained by PMA-PCR and culture on naturally contaminated chickens was high (R² = 0.844). The amplification efficiency of the Q-PCR method was not affected by the chicken rinse matrix or by the species of Campylobacter. No Q-PCR signals were obtained from artificially inoculated chicken rinse when PMA sample treatment was applied. In conclusion, this study presents a rapid tool for producing reliable quantitative data on viable Campylobacter bacteria in chicken carcass rinse. The proposed method does not detect DNA from dead Campylobacter bacteria but recognizes the infectious potential of the VBNC state and is thereby able to assess the effect of control strategies and provide trustworthy data for risk assessment.As Campylobacter remains the leading cause of food-borne bacterial gastrointestinal disease in large parts of the developed world (34), much effort is devoted to improving the detection and elimination of the pathogen, especially in poultry. The ultimate goal is to supply consumers with fresh, Campylobacter-free poultry products, but in order to achieve that goal, it is important to gain more insight into the epidemiology of Campylobacter, to make quantitative risk assessments, and to improve control and intervention strategies.Traditional culture-based detection of Campylobacter bacteria, including enrichment, isolation, and confirmation, is a time-consuming procedure requiring 5 to 6 working days (4, 14). Furthermore, bacterial cells may enter a viable but nonculturable (VBNC) state in which they may have the potential to cause human infection (37) but are not detected by the culture method. The introduction of real-time quantitative PCR (Q-PCR) has enabled faster, more sensitive, and less labor-intensive quantitative detection. Q-PCR methods for food-borne Campylobacter jejuni and C. coli in poultry, which is recognized as an important source of human Campylobacter infections, have been published (11, 12, 15, 38, 46). However, since control strategies mostly focus on reduction of the number of bacterial cells on the chicken carcass, the usefulness of these Q-PCR methods for risk assessment could be limited, since they detect all of the Campylobacter bacteria present in a sample, including the dead cells.The Q-PCR method described in the present study quantifies the three major food-borne Campylobacter species (C. jejuni, C. coli, and C. lari), thereby covering all possible prevalence shifts and coinfections. The PCR assay was previously validated according to the Nordic Organization for Validation of Alternative Microbiological Methods (NordVal) and is certified for detection of Campylobacter bacteria in chickens, cloacal swabs, and boot swabs (7). The present study concerns its suitability for the quantification of Campylobacter bacteria in chicken carcass rinse. Furthermore, a propidium monoazide (PMA) sample treatment step has been incorporated into the method (PMA-PCR), ensuring the quantification of only viable cells with intact membranes. PMA can intercalate into the double-helical DNA available from dead cells with compromised membranes, and upon extensive visible light exposure, cross-linking of the two strands of DNA occurs, leaving it unavailable for PCR amplification (30). PMA is a chemical alteration (additional azide group) of propidium iodide (PI), one of the most frequently applied non-membrane-permeating dyes in flow cytometry, and it can be expected to have the same permeating potential as PI (29). This could be of value from a food safety perspective, since PI penetrates only permeabilized cells and not cells with intact membranes (including the Campylobacter VBNC state), which can still cause infection. Nocker et al. demonstrated that no uptake of PMA occurred in bacterial cells with intact membranes, and PMA was exclusively found in bacteria with compromised membranes (31).PMA sample treatment combined with real-time PCR for detection of viable pathogens has been tested successfully on Listeria monocytogenes and Escherichia coli O157:H7 (31, 36). However, these studies were limited to laboratory-cultured strains and the methods have not been validated on naturally infected samples with the pathogen embedded in a food matrix.This is the first study to establish a correlation between results obtained by PMA-PCR and culture-based enumeration of Campylobacter bacteria for a large number of naturally infected chickens.