Epidemic curve of influenza-like illness in Japan.

<p>Number of reported cases of influenza-like illness per sentinel surveillance site per week in Japan, from week 36, 2004 through week 35, 2010.</p

Age distribution of influenza-A associated encephalopathy by patient visits.

<p>Number of influenza A-associated encephalopathy cases per estimated 1,000,000 patient visits by age, 2006–2010.</p

Number of reported cases of influenza-associated encephalopathy (fatal cases) by virus type in Japan, 2004–2010.

<p>ILI: influenza like illness.</p><p>IAE: influenza-associated encephalopathy.</p>*<p>Reported as influenza A from week 36, 2004 through week 27, 2009.</p>†<p>Reported as influenza B from week 36, 2004 through week 35, 2010.</p>‡<p>Reported as influenza A (H1N1) 2009 or influenza A from week 28, 2009 through week 35, 2010.</p>§<p>Reported as influenza A (H3N2) in week 24, 2010.</p

Epidemic curve of influenza-associated encephalopathy and other encephalopathy/encephalitis in Japan.

<p>Number of cases of influenza-associated encephalopathy and acute encephalitis/encephalopathy other than influenza in Japan, from week 36, 2004 through week 35, 2010.</p

Age distribution of patients with influenza-like illness who consulted a medical facility.

<p>Estimated number of patients with influenza-like illness who consulted with a medical facility by age, 2006–2010.</p

Age distribution of influenza-A associated encephalopathy per population.

<p>Number of influenza A-associated encephalopathy cases per 1 million population by age, 2004–2010.</p

Table_1_Novel insights into genetic characteristics of blaGES-encoding plasmids from hospital sewage.DOCX

IntroductionThe prevalence of Guiana extended-spectrum (GES)-type carbapenemase producers is increasing worldwide, and hospital water environments are considered as potential reservoirs. However, the genetic features underlying this resistance are not yet fully understood. This study aimed to characterize blaGES-encoding plasmids from a single-hospital sewage sample in Japan.MethodsCarbapenemase producers were screened using carbapenemase-selective agar and polymerase chain reaction. Whole-genome sequencing analyzes were performed on the carbapenemase-producing isolates.ResultsEleven gram-negative bacteria (four Enterobacter spp., three Klebsiella spp., three Aeromonas spp., and one Serratia spp.) with blaGES-24 (n = 6), blaGES-6 (n = 4), and blaGES-5 (n = 1) were isolated from the sewage sample. Five blaGES-24 and a blaGES-5 were localized in IncP-6 plasmids, whereas three blaGES-6 plasmids were localized in IncC plasmids with IncF-like regions. The remaining blaGES-6 and blaGES-24 were, respectively, localized on IncFIB-containing plasmids with IncF-like regions and a plasmid with an IncW-like replication protein. The IncP-6 and IncW-like plasmids had a close genetic relationship with plasmids from Japan, whereas the IncC/IncF-like and IncFIB/IncF-like plasmids were closely related to those from the United States and Europe. All blaGES genes were located on the class 1 integron cassette of the Tn3 transposon-related region, and the IncC/IncF-like plasmid carried two copies of the integron cassette. Eight of the eleven blaGES-encoding plasmids contained toxin-antitoxin system genes.DiscussionThe findings on the plasmids and the novel genetic content from a single wastewater sample extend our understanding regarding the diversity of resistance and the associated spread of blaGES, suggesting their high adaptability to hospital effluents. These findings highlight the need for the continuous monitoring of environmental GES-type carbapenemase producers to control their dissemination.</p

Image_1_Novel insights into genetic characteristics of blaGES-encoding plasmids from hospital sewage.pdf

IntroductionThe prevalence of Guiana extended-spectrum (GES)-type carbapenemase producers is increasing worldwide, and hospital water environments are considered as potential reservoirs. However, the genetic features underlying this resistance are not yet fully understood. This study aimed to characterize blaGES-encoding plasmids from a single-hospital sewage sample in Japan.MethodsCarbapenemase producers were screened using carbapenemase-selective agar and polymerase chain reaction. Whole-genome sequencing analyzes were performed on the carbapenemase-producing isolates.ResultsEleven gram-negative bacteria (four Enterobacter spp., three Klebsiella spp., three Aeromonas spp., and one Serratia spp.) with blaGES-24 (n = 6), blaGES-6 (n = 4), and blaGES-5 (n = 1) were isolated from the sewage sample. Five blaGES-24 and a blaGES-5 were localized in IncP-6 plasmids, whereas three blaGES-6 plasmids were localized in IncC plasmids with IncF-like regions. The remaining blaGES-6 and blaGES-24 were, respectively, localized on IncFIB-containing plasmids with IncF-like regions and a plasmid with an IncW-like replication protein. The IncP-6 and IncW-like plasmids had a close genetic relationship with plasmids from Japan, whereas the IncC/IncF-like and IncFIB/IncF-like plasmids were closely related to those from the United States and Europe. All blaGES genes were located on the class 1 integron cassette of the Tn3 transposon-related region, and the IncC/IncF-like plasmid carried two copies of the integron cassette. Eight of the eleven blaGES-encoding plasmids contained toxin-antitoxin system genes.DiscussionThe findings on the plasmids and the novel genetic content from a single wastewater sample extend our understanding regarding the diversity of resistance and the associated spread of blaGES, suggesting their high adaptability to hospital effluents. These findings highlight the need for the continuous monitoring of environmental GES-type carbapenemase producers to control their dissemination.</p

Distribution of antimicrobial resistance genes among ESBL-producing <i>Enterobacter</i> spp.

*<p>All <i>qnrA</i> were <i>qnrA1</i>.</p

Dendrogram and PFGE of <i>Xba</i>I-digested genomic DNAs from ESBL-producing <i>Enterobacter</i> species.

<p>EC: <i>Enterobacter cloacae</i>, EA: <i>Enterobacter aerogenes</i>. Strain No. and PFGE type correspond to those in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0037967#pone-0037967-t002" target="_blank">Table 2</a>.</p