Contamination is a prevalent issue with reprocessed levered endoscopes. The number of infections caused by resistant enterobacteriaceae in patients due to contaminated endoscopes increased to the point that the United States Food and Drug Administration released a safety alert to health care facilities that perform endoscopic retrograde cholangiopancreatography (ERCP). The purpose of this descriptive project was to evaluate if levered endoscopes used in ERCP procedures met high level disinfection criteria, were properly processed, and were germ free after reprocessing. The project was supported by 2 theories: the middle range theory of patient advocacy and the germ theory. Data (counts and percentages) were collected from testing 150 endoscopes at each of 4 facilities within an organization regarding the effectiveness of the reprocessing of the levered endoscopes. According to the project findings, there was a 7% average germ-free failure rate across the sites after the initial reprocessing. The cleaning process of the levered endoscopes allowed bacteria to remain on the scopes after the manufacturer-recommended cleaning was completed at the sites. Standardization of the organization's cleaning process and improvement in the national protocols were recommended. The project supported protecting the safety of endoscopy patients by identifying that the cleaning process could be improved to prevent introduction of infectious bacteria through a procedure. The results will be informative for laboratory staff who clean levered endoscopes, physicians who use the scopes in patient procedures, patients who undergo the procedures, and nurses who are tasked with improving patient safety in perioperative environments.

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Bacteriophages (phages) are the smallest biological entity on the planet. They provide vast amounts of valuable knowledge to biologists. Phage genomes are relatively simple compared to the organisms they infect (prokaryotes) and yet continually point to the complexity surrounding molecular- and microbiological mechanisms of life. By studying phages we can learn of the systems of gene expression, protein interaction and DNA organization. Phages are useful not only from an academic perspective, but may also have useful clinical applications. In the face of the rise of antibiotic-resistant bacterial “super pathogens”, scientists and researchers turn to phages as alternative treatments to these types of infections. Phages are capable of infecting and killing even the deadliest of bacterial pathogens, such as carbapenem-resistant Enterobacteriaceae (CRE) or Bacillus anthracis, and may prove increasingly useful in the future for combatting harmful pathogens. This thesis looks at several aspects of phage biology—from the underlying genetics contributing to phage virulence, to the clinical application of phage therapy to treat infections. First, a look at CRE-Klebsiella pneumoniae isolates and phages capable of infecting some strains may reveal a potential therapeutic approach in the future. Additionally, genomic analysis reveals interesting features that may explain aspects of phage virulence and evolutionary history. Then, a collection of genetically diverse phages is used in infection assays on pathogenic strains of Bacillus anthracis to establish the first-reported phages capable of infecting these strains. Finally, the process of preparing phage samples for therapeutic application is explored in-depth to conclude with discussion of clinical application. During the course of these projects over 25 phages were isolated, as many phage genomes were assembled and annotated, resulting in the preparation of two genome announcements and near-completion of two publishable first-author papers (chapters II and III). In addition, participation in a variety of collaborative efforts may lead to a handful of co-author papers and on various topics, including phage biology and application.

京都大学 / 新制・論文博士 / 博士(工学) / 乙第13581号 / 論工博第4212号 / 新制||工||1990(附属図書館) / (主査)教授 松原 誠二郎, 教授 中尾 佳亮, 教授 浦山 健治 / 学位規則第4条第2項該当 / Doctor of Philosophy (Engineering) / Kyoto University / DFAM

Background. Carbapenem-resistant Enterobacteriaceae, including Escherichia coli and Klebsiella pneumoniae, are newly emerging pathogens of public health importance. Currently no nationally representative or mandatory surveillance or reporting system exists to examine trends of these important pathogens. Objective. The purpose of the current study was to estimate trends in overall microbial burden and carbapenem resistance in E. coli and K. pneumoniae and to understand the extent to which hospitals which report to voluntary surveillance systems represent all hospitals in the United States. Design. We conducted a descriptive study to compare the hospitals participating in voluntary reporting systems of the University HealthSystem Consortium and the National Healthcare Safety Network with the Healthcare Utilization Project’s Nationwide Inpatient Sample, a nationally representative sample of hospital discharges. Methods. Descriptive analyses examined hospital characteristics (region, bed size, hospital control, teaching status, case mix index) and patient characteristics (age, sex, race/ethnicity, admission source, admission type, discharge status, primary payer) of participant hospitals versus all US hospitals. ICD-9-CM codes identified discharges coded for E. coli and K. pneumoniae diagnoses; linear regression was used to evaluate trends in overall microbial burden of E. coli and K. pneumoniae in all US Hospitals and US Academic Centers. Trends in E. coli and K. pneumoniae resistance to carbapenem were also evaluated in hospitals participating in voluntary surveillance systems (n=13). Results. Between 2002 and 2007, slight increasing trends in burden of both E. coli and K. pneumoniae were observed (E. coli: slope = 0.0537; K. pneumoniae slope = 0.0168). Hospitals participating in voluntary surveillance systems are larger and care for fewer elderly patients than all US hospitals. Conclusions. These results suggest that hospitals that participate in voluntary surveillance systems like the National Healthcare Safety Network and the University HealthSystem Consortium may underrepresent trends in smaller hospitals, as well as those that treat elderly patients. Increasing overall burden of infection due to these isolates only reinforces the importance carbapenem resistance in E. coli and K. pneumoniae. This important public health threat may warrant the creation of a national, mandatory reporting system for these and other antimicrobial resistant organisms.

This work will look at two factors that add to the diversity of carbapenem resistant bacteria. First, it focuses on the diversity of carbapenemase resistance plasmids. 446 plasmids were characterized by size, gene content and replicon groups. We identified that on average, over 30% of the encoded proteins on each plasmid have an unknown function. Plasmid sizes ranged from 1.6kb to 500kb, with an average of around 100kb and median of 80kb. Additionally, six replicon groups account for 80% of all the carbapenemase resistance plasmids. We also highlight the lack of data available for carbapenemase carrying plasmids from bacterial genera other than Escherichia and Klebsiella, and plasmids that carry the New Delhi metallo-β- lactamase or the Verona-integron encoded metallo-β-lactamase. Second, we characterized the β-lactamase diversity of a single carbapenemase resistant Klebsiella pneumoniae. This isolate encodes six distinct β-lactamases, all of which are functional, and three of which are redundant. Additionally, we determined that the CTX-M-15 cephalosporinase imparts a greater fitness when grown in aztreonam (a monobactam) than ceftazidime (a cephalosporin). Finally, we show that individually, these β-lactamases do not account for the elevated levels of resistance seen in the parent strain, indicating that the passive resistance mechanisms (i.e. efflux pumps, altered membrane porins) may play a larger role than originally thought.

This study focuses on the question of the epidemiology of resistance to antibiotics in Acinetobacter baumannii, which is nowadays one of the most problematic bacterial patho- gens associated with failing antimicrobial therapy. Its aim was to define population-genetic properties, epidemiology and the nature of multidrug resistance for a sample of the current population of A. baumannii from Czechia. A total of 55 isolates were collected in eight medi- cal facilities in central Bohemia from October 2016 to May 2018. The isolates were assessed for their identity at the species, clonal and strain levels as well as resistance phenotype and genotype; they were classified into five clonal groups, each of which encompassed isolates that were likely to be epidemiologically related. The 55 isolates studied belonged, nearly exclusively, to global clone ECII, with 53 % of them forming a genetically relatively homoge- neous group characterized by extensive resistance to antibiotics (susceptible only to col- istin), the presence of genes encoding ArmA a OXA-23 (resistance to all aminoglycosides and carbapenems) and spread in all locations. The in-depth epidemiological analysis of isolates from the city of Příbram and its vicinity indicated the regional spread of two strains, one of which belonged to the...

Fundação de Amparo a Pesquisa do Estado de Minas Gerais / Introduction: Has been observed the global spread of different variants of P. aeruginosa that is often associated with increased virulence or the emergence of new antimicrobial resistance genotypes. There are few studies describing the association of the Type III Secretion System (TTSS) with antibiotic resistance and outcome of patients with pneumonia and bacteremia. Objectives: Determine the relation among resistance to carbapenems and fluoroquinolones and the Type III Secretion System (TTSS) effector genotype and its association with the poor prognostic in patients with ventilator-associated pneumonia (VAP) and bacteremia, identify mutations in the Quinolone Resistance Determining Regions (QRDRs), Metallo-β-Lactamase genes (MβL), virulence genes (algD, lasB e toxA) and clonal spread of isolates producing MβL. Material and Methods: A retrospective cohort was conducted to determine the risk factors for 30-day mortality in patients with the first episode of bacteremia (157 patients) and VAP (60 patients) caused by P. aeruginosa. Genes blaIMP, blaVIM, blaSIM, blaGIM and blaSPM, TTSS genes (exoT, exoS, exoY, exoU ) and virulence genes (lasB, algD, toxA) were detected by PCR; the sequencing was conducted for QRDR genes (gyrA e parC) on fluoroquinolone-resistant strains and the Pulsed-Field Gel Electrophoresis (PFGE) for molecular typing of positive strains for the MβL genes Results: The multivariate analysis showed that predictors independently associated with death in patients with bacteremia were inappropriate therapy and cancer. Carbapenem resistance was more frequent among strains of VAP (53.3%), however with the detection of MβL genes in one isolate (blaIMP), unlike blood, where the frequency of these genes was 16.1%, being 10.7% blaSPM genotype and 5.4% blaVIM genotype. The exoS gene was found in all blood and lung isolates and the exoU gene only in 9.4%. Substitution of threonine to isoleucine at position 83 in gyrA was the most frequent mutation among fluoroquinolone-resistant strains. It was detected a mutation at position 91 in parC gene (Glu91Lys) associated with mutation in gyrA (Thre83Ile) in a strain of extensively drug-resistant P. aeruginosa, exoT+exoS+exoU+ genotype, isolate from lung, not described in Brazil yet. Among the strains that harboring the TTSS virulence genes it was observed high resistance to gentamicin (93.7%) and low for amikacin (37.5%). The evaluation of the clonal relationship between isolates producing blaSPM, blaVIM and blaIMP genes showed similarity (more than 80%) among the blaSPM strains, which was not observed for those producing blaVIM gene. Conclusions: Our results confirm previous findings regarding the spread of blaSPM clone, with indirect evidence of its cross-spread in our hospital and polyclonal those containing the blaVIM gene. Inappropriate therapy is significant factor for poor prognosis among patients with bacteremia caused by multidrug-resistant P. aeruginosa , independent of the virulence TTSS genotype associated. / Introdução: Vem sendo observado a disseminação global de diferentes variantes de P. aeruginosa que está frequentemente associada a maior virulência ou a emergência de novos genótipos de resistência aos antimicrobianos. Há poucos estudos descrevendo a associação do Sistema de Secreção Tipo III (TTSS) com resistência aos antibióticos e evolução dos pacientes com pneumonia e bacteremia. Objetivos: Determinar a relação entre resistência a fluorquinolonas e carbapenêmicos e a virulência de Pseudomonas aeruginosa pelo Sistema de Secreção Tipo III e sua associação com pior prognóstico em pacientes com Pneumonia Associada a Ventilação Mecânica (PAV) e bacteremia, identificar mutações na Região Determinante de Resistência as Quinolonas (QRDR), genes para Metalo-β-Lactamase (MβL), genes de virulência (algD, lasB e toxA) e disseminação clonal das amostras produtoras de MβL. Material e Métodos: Foi realizada uma coorte retrospectiva para determinar os fatores de risco para mortalidade em 30 dias em pacientes com primeiro episódio de bacteremia (157 pacientes) e PAV (60 pacientes) por P. aeruginosa. Os genes blaIMP, blaVIM, blaSIM, blaGIM e blaSPM, os genes do TTSS (exoT, exoS, exoY, exoU ) e os genes de virulência (lasB, algD, toxA) foram detectados por PCR; o sequenciamento foi realizado para os genes do QRDR (gyrA e parC) nas cepas resistentes a fluorquinolonas e o Pulsed-Field Gel Electrophoresis (PFGE) para tipagem molecular das amostras positivas para o gene produtor de MβL. Resultados: A análise multivariada mostrou que os preditores independentemente associados com mortalidade nos pacientes com bacteremia foram terapia antimicrobiana inapropriada e câncer. A resistência aos carbapenêmicos foi maior entre as amostras de PAV (53,3%), porém com a detecção dos genes que codificam MβL em apenas um isolado (blaIMP), ao contrário do sangue, onde a frequência desses genes foi de 16,1%, sendo 10,7% blaSPM e 5,4% blaVIM. O gene exoS foi encontrado em todas as amostras avaliadas de sangue e pulmão e o gene exoU em apenas 9,4% das mesmas. A substituição de uma treonina por isoleucina na posição 83 no gene gyrA foi a mais frequente entre as cepas resistentes a fluorquinolonas. Foi detectada uma mutação na posição 91 no gene parC (Glu91Lys) associada com a mutação em gyrA (Thre83Ile) em uma amostra de P. aeruginosa ,isolada do pulmão, extensivamente resistente, do genótipo exoT+exoS+exoU+ , ainda não descrita no Brasil. Entre as amostras que carreavam os genes de virulência TTSS observou-se alta resistência a gentamicina (93,7%) e baixa para amicacina (37,5%). A avaliação da relação clonal entre as amostras contendo os genes blaSPM, blaVIM e blaIMP , apresentou alta similaridade (maior que 80%), naquelas contendo blaSPM, o que não foi observado para as amostras contendo o gene blaVIM. Conclusões: Nossos resultados confirmam achados prévios com relação a disseminação do clone blaSPM, com evidências indiretas da sua disseminação cruzada no nosso hospital e policlonal daquelas contendo o gene blaVIM. A terapia inapropriada é fator significativo para pior prognóstico entre os pacientes com bacteremia por P. aeruginosa multirresistente, independente do genótipo de virulência TTSS associado. / Mestre em Imunologia e Parasitologia Aplicadas

The treatment options for multidrug resistant bacteria are dwindling and it is an important issue of research in medicine to solve. One of the more problematic bacterial species is Klebsiella pneumoniae, it can cause infections with high morbidity that are difficult to treat. Common antibiotics for treatment of these infections are carbapenems but K. pneumoniae can produce enzymes called carbapenemases that can hydrolyze carbapenems and most other beta-lactam antibiotics. In this study carbapenemase genes were introduced chromosomally to a previously susceptible K. pneumoniae strain using λ-Red recombineering. Further constructs were made with non-functional porins to examine how they affect combination treatment with carbapenems. Antibiotic combination therapy was evaluated against constructed carbapenemase- (KPC-2, NDM-1 and OXA-48) producing K. pneumoniae strains. Screening was done using time-lapse microscopy (oCelloScope), and combinations with better effect than treatment with a single antibiotic were chosen for time-kill assays. The results shows that a triple combination of colistin, meropenem and the beta-lactamase inhibitor avibactam gives an improved effect, up to twice the effect compared to monotherapy and up to 1.8 times increased effect compared to double combination. The synergistic effect was greater when adding colistin to treat the strains with non-functional porins, indicating that colistin can increase the permeability for other antibiotics into the cell. This is an interesting finding that need to be researched further.

Antibiotic resistant bacteria are threatening human health, and the resistance is progressingfaster than the development of new antimicrobial compounds. Antibiotic resistant infections cost enormous sums of money and resources, but most importantly human lives. Therefore, early prediction and detection of antibiotic resistance in bacteria are research areas of high priority. The use of analytical instruments such as matrix-assisted laser desorption/ionization time of flight (MALDI-TOF) mass spectrometry (MS) is a powerful tool for research in antibiotic resistant bacteria, both as quick microbe identification and for other areas in the field.Due to its relatively easy interpretable spectra provided by the soft ionization technique, and ability to ionize macromolecules without compromising sample integrity, it has also been used for biomarker screening for detection of antimicrobial resistance. Although these studies have shown promising results, the area is still progressing and needs further method development and standardized protocols. This study aimed to use MALDI-TOF MS for carbapenemaseassociated screening in Klebsiella oxytoca. The presumed key spectral peaks would derive from presence of the enzyme Verona integron-encoded metallo-β-lactamase, type 1 (VIM-1), and would not be found if VIM-1 were absent. The isolates, carrying the enzyme, used in the study were isolated from wastewater and river water in Örebro, Sweden. Bacteria genus and species was determined by MALDI-TOF identification, whereupon the microbes were tested for antibiotic susceptibility using the disk diffusion method. Carbapenem hydrolysis assay was used to confirm the presence/absence of functional carbapenemase. A genotypic confirmation was performed by polymerase chain reaction and gel electrophoresis. Mass spectra from MALDI-TOF were compared for identification of possible biomarker peaks that could indicate carbapenem resistance. Nine key mass spectral peaks were found that could potentially be used as biomarkers in future studies. The peaks differentiated two groups of Klebsiella oxytocaisolates, one group producing functional carbapenemase and one group that did not, consistent with the aim of this study.