Multilevel competing risk models to evaluate the risk of nosocomial infection

Introduction Risk factor analyses for nosocomial infections (NIs) are complex. First, due to competing events for NI, the association between risk factors of NI as measured using hazard rates may not coincide with the association using cumulative probability (risk). Second, patients from the same intensive care unit (ICU) who share the same environmental exposure are likely to be more similar with regard to risk factors predisposing to a NI than patients from different ICUs. We aimed to develop an analytical approach to account for both features and to use it to evaluate associations between patient- and ICU-level characteristics with both rates of NI and competing risks and with the cumulative probability of infection. Methods We considered a multicenter database of 159 intensive care units containing 109,216 admissions (813,739 admission-days) from the Spanish HELICS-ENVIN ICU network. We analyzed the data using two models: an etiologic model (rate based) and a predictive model (risk based). In both models, random effects (shared frailties) were introduced to assess heterogeneity. Death and discharge without NI are treated as competing events for NI. Results There was a large heterogeneity across ICUs in NI hazard rates, which remained after accounting for multilevel risk factors, meaning that there are remaining unobserved ICU-specific factors that influence NI occurrence. Heterogeneity across ICUs in terms of cumulative probability of NI was even more pronounced. Several risk factors had markedly different associations in the rate-based and risk-based models. For some, the associations differed in magnitude. For example, high Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were associated with modest increases in the rate of nosocomial bacteremia, but large increases in the risk. Others differed in sign, for example respiratory vs cardiovascular diagnostic categories were associated with a reduced rate of nosocomial bacteremia, but an increased risk. Conclusions A combination of competing risks and multilevel models is required to understand direct and indirect risk factors for NI and distinguish patient-level from ICU-level factors.

The beta-glucoside genes of Klebsiella aerogenes: conservation and divergence in relation to the cryptic bgl genes of Escherichia coli

The ability to metabolize aromatic beta-glucosides such as salicin and arbutin varies among members of the Enterobacteriaceae. The ability of Escherichia coli to degrade salicin and arbutin appears to be cryptic, subject to activation of the bgl genes, whereas many members of the Klebsiella genus can metabolize these sugars. We have examined the genetic basis for beta-glucoside utilization in Klebsiella aerogenes. The Klebsiella equivalents of bglG, bglB and bglR have been cloned using the genome sequence database of Klebsiella pneumoniae. Nucleotide sequencing shows that the K. aerogenes bgl genes show substantial similarities to the E. coli counterparts. The K. aerogenes bgl genes in multiple copies can also complement E. coli mutants deficient in bglG encoding the antiterminator and bglB encoding the phospho-beta-glucosidase, suggesting that they are functional homologues. The regulatory region bglR of K aerogenes shows a high degree of similarity of the sequences involved in BglG-mediated regulation. Interestingly, the regions corresponding to the negative elements present in the E. coli regulatory region show substantial divergence in K aerogenes. The possible evolutionary implications of the results are discussed. (C) 2003 Federation of European Microbiological Societies. Published by Elsevier Science B.v. All rights reserved.

Carbapenem-resistant and carbapenem-susceptible isogenic isolates of Klebsiella pneumoniae ST101 causing infection in a tertiary hospital

Background: In this study we describe the clinical and molecular characteristics of an outbreak due to carbapenem-resistant Klebsiella pneumoniae (CR-KP) producing CTX-M-15 and OXA-48 carbapenemase. Isogenic strains, carbapenem-susceptible K. pneumoniae (CS-KP) producing CTX-M-15, were also involved in the outbreak. Results: From October 2010 to December 2012 a total of 62 CR-KP and 23 CS-KP were isolated from clinical samples of 42 patients (22 had resistant isolates, 14 had susceptible isolates, and 6 had both CR and CS isolates). All patients had underlying diseases and 17 of them (14 patients with CR-KP and 3 with CS-KP) had received carbapenems previously. The range of carbapenem MICs for total isolates were: imipenem: 2 to >32 mu g/ml vs. <2 mu g/ml; meropenem: 4 to >32 mu g/ml vs. <2 mu g/ml; and ertapenem: 8 to >32 mu g/ml vs. <2 mu g/ml. All the isolates were also resistant to gentamicin, ciprofloxacin, and cotrimoxazole. Both types of isolates shared a common PFGE pattern associated with the multilocus sequence type 101 (ST101). The bla(CTX-M-15) gene was detected in all the isolates, whereas the bla(OXA-48) gene was only detected in CR-KP isolates on a 70 kb plasmid. Conclusions: The clonal spread of K. pneumoniae ST101 expressing the OXA-48 and CTX-M-15 beta-lactamases was the cause of an outbreak of CR-KP infections. CTX-M-15-producing isolates lacking the blaOXA-48 gene coexisted during the outbreak.

Estudo sobre as mudanças fenotípicas conferidas por plasmídios R provenientes de Klebsiella pneumoniae e Escherichia coli em transconjugantes de E. coli K12-R23

Plasmídios são DNA extracromossômicos, com capacidade de se duplicarem de forma independente das células que os albergam, e são responsáveis pela expressão de uma variedade de características, como fatores de virulência. O material do presente estudo se constituiu da cepa receptora E. coli K12-R23, e de cepas de Klebsiella pneumoniae e de Escherichia coli, doadoras de plasmídios R e transconjugantes. O objetivo do presente estudo foi analisar os fenótipos conferidos em cepas transconjugantes de ambas bactérias pela transferência de plasmídios R de cepas doadoras para a receptora. Para a análise dos fenótipos, utilizaram-se, nas cepas do estudo, algumas variáveis: sensibilidade a antimicrobianos e a ERO, aderência a células HEp-2, e formação de slime e de biofilme. O marcador da presença de plasmídio, neste trabalho, foi a presença de resistênca à gentamicina nas cepas doadoras. Os resultados indicaram que houve transferência de plasmídio, pois as cepas transconjugantes de K. pneumoniae e de E. coli apesentaram este marcador (foram resistentes à gentamicina); além disso, as cepas transconjugantes mostraram perfis distintos da receptora em relação à sensibilidade aos antimicrobianos, às ERO, aos padrões de aderência às células HEp-2 e à formação de slime, apesar de a formação de biofilme nestas cepas não ter sofrido modificações. Observou-se, contudo, que várias características das cepas doadoras não foram encontradas nas cepas transconjugantes de E. coli e de K. pneumoniae.

植生克雷伯氏菌（Klebsiella planticola 19-1）nifA-like基因的克隆

植生克雷伯氏菌(Klebsiella planticola 19-1)是从新疆鄯善地区玉米根际分离得到的一株联合固氮菌。在40℃高温下有较强的乙炔还原活性。 本工作利用Southern Blot分子杂交技术, 以Klebsiella pneumoniae的nifA为探针，证明了在K．planticola 19-1中存在nifA-like基因，由nifH-lacZ实验推论其nifA-like基因产物对高温相对稳定。经过大质粒电泳和Southern Blot分子杂交，发现nifA-like基因定位于染色体外的大质粒上。本工作进一步克隆了含有K．plonticola 19-1的nifA-like基因的DNA片段，做了它的限制性酶切图谱，并将nifA-like基因初步定位。

联合固氮菌Klebsiella oxytoca SA2和水稻幼苗的相互作用

从内蒙流沙地先锋植物沙竹（Psammochloa mongokca）内分离到一株内生细菌，经鉴定定名为Klebsiella oxytoca SA-2 K.oxytoca SA-2兼性厌氧固氮，NH4+抑制其固氮酶合成。部分抑制固氮酶活性;N03 -抑制其固氮酶的合成和活性。 60℃灭活K.oxytoca SA-2整体菌免疫兔子得到抗血清。免疫印迹表明此抗血清具K.oxytoca SA-2种特异性。石蜡切片免疫金银染色结合显微观察发现K.oxytoca SA-2定殖于沙竹叶鞘薄壁细胞和叶片的薄壁细胞内。 K.oxytoca SA-2在半固体培养基中接种水稻幼苗，限菌培养21天，根内重新分离的数量达l06 cfu/g．FWroot，但K.oxytoca SA-2在富养的土壤中生长良好，表现为兼性内生菌。 限菌培养水稻（Oryza sativa）幼苗，石蜡切片免疫金银染色结合显微观察研究了的K.oxytoca SA-2的侵染特性．K.oxytoca SA-2可以通过侧根发生处和表皮细胞胞间层进入根内，在皮层薄壁细胞间隙大量定殖，在解体和看似完整的薄壁细胞内也有定殖，在根和茎中柱内K.oxytoca SA-2进入了木质部导管。在根基，K.oxytoca SA-2大量侵入了已解体的内皮层和中柱鞘细胞，植物细胞在K.oxytoca SA-2侵入后解体，可能表现为严格的局部超敏反应。 接种K.oxytoca SA-2 21天，水稻地上苗部分没有发现肉眼和显微可见的病症。与对照相比，接种K.oxytoca SA-2显著促进限氮培养水稻幼苗的生长。由于K.oxytoca SA-2在限碳限氮培养基和水稻幼苗共培养时能分泌NH4+和植物激素，它可能通过向水稻幼苗提供氮素和分泌植物激素促进植物生长。而且用固氮酶铁蛋白抗血清进行免疫金银染色发现定殖在根基皮层薄壁细胞胞间层和细胞间隙，木质部导管和茎基木质部导管的K.oxytoca SA-2可以表达固氮酶，固氮参与了K.oxytoca SA-2在水稻幼苗中的内生。 培养基内碳源（苹果酸）和培养温度对K.oxytoca SA-2和水稻幼苗相互作用的影响也进行了研究。 研究表明，K.oxytoca SA-2作为兼性内生固氮菌，能够和植物紧密联合，并在植物体内开拓一个有利的生态位固氮，而且K.oxytoca SA-2可以分泌NH4+和植物激素，在和植物相互作用中使植物受益。