Possible Transmission of Pandemic (HIN1) 2009 Virus with Oseltamivir Resistance

To the Editor: In March 2009, a new strain of influenza A (H1N1) virus of swine origin emerged; the virus had crossed the species barrier to humans and acquired the capability of human-to-human transmission. Soon after, the World Health Organization raised the worldwide pandemic alert to level 6 (www.who.int/en), declaring the first influenza pandemic in the past 42 years. The virus was named influenza A pandemic (H1N1) 2009 virus. The illness caused by this virus is particularly dangerous for pregnant women and for patients with chronic diseases (1). The preferred treatment is a neuraminidase inhibitor, zanamivir or oseltamivir (2). Around the world, several dozen cases of resistance to oseltamivir in persons with or without exposure to the drug have been reported (3). However, only limited information is available with regard to initial infections with oseltamivir-resistant viruses (4). We report a case of possible human-to-human transmission of pandemic (H1N1) 2009 virus in Israel. After the recent discovery of oseltamivir-resistant strains, we conducted a retrospective study of oseltamivir-resistance mutations in viral RNA amplified from specimens from patients hospitalized>1 week with pandemic (H1N1) 2009. All samples were first tested for the H275Y mutation by using an in-house real-time reverse transcription–PCR (RT-PCR) assay developed a

Forty Five Percent of the Israeli Population were Infected with the Influenza B Victoria virus During the Winter season 2015-16

While infection with influenza A viruses has been extensively investigated, infections with influenza B viruses which are commonly categorized into the highly homologous Victoria and Yamagata lineages, are less studied, despite their considerable virulence. Here we used RT-PCR assays, hemagglutination inhibition assays and antibody titers to determine the levels of influenza B infection. We report of high influenza B Victoria virus prevalence in the 2015-16 winter season in Israel, affecting approximately half of the Israeli population. We further show that the Victoria B virus infected individuals of all ages and that it was present in the country throughout the entire winter season. The vaccine however included the inappropriate Yamagata virus. We propose that a quadrivalent vaccine, that includes both Yamagata and Victoria lineages, should be considered for future influenza vaccination

Genetic Divergence of Influenza A(H3N2) Amino Acid Substitutions Mark the Beginning of the 2016-2017 Winter Season in Israel

BACKGROUND: Influenza vaccine composition is reevaluated each year due to the frequency and accumulation of genetic changes that influenza viruses undergo. The beginning of the 2016-2017 influenza surveillance period in Israel has been marked by the dominance of influenza A(H3N2). OBJECTIVES: To evaluate the type, subtype, genetic evolution and amino acid substitutions of influenza A(H3N2) viruses detected among community patients with influenza-like illness (ILI) and hospitalized patients with respiratory illness in the first weeks of the 2016-2017 influenza season. STUDY DESIGN: Respiratory samples from community patients with influenza-like illness and from hospitalized patients underwent identification, subtyping and molecular characterization. Hemagglutinin sequences were compared to the vaccine strain, phylogenetic tree was created, and amino acid substitutions were determined. RESULTS: Influenza A(H3N2) predominated during the early stages of the 2016-2017 influenza season. Noticeably, approximately 20% of community patients and 36% of hospitalized patients, positive for influenza CONCLUSIONS: Characterization of the 2016-2017 A(H3N2) influenza viruses is imperative for determining the future influenza vaccine composition

Emergence of Klebsiella pneumoniae Carbapenemase (blaKPC-2) in members of the Enterobacteriaceae family in Palestine

Abstract Background: The global spread of carbapenem resistant Enterobacteriaceae (CRE) has limited the physicians’ antimicrobial treatment options of infected patients. CRE’s which carry the Klebsiella pneumonia Carbapenemase (blaKPC) resistance mechanism have been rapidly spreading in many parts of the world, and have been responsible for high patients’ morbidity and mortality. Methods: Two protocols recommended by the Center for Disease Control and Prevention (CDC) were followed to detect CRE’s in Palestine. In addition, the antimicrobial sensitivity patterns for several antibiotic classes were determined for the isolated CRE’s by the disc diffusion method according to the clinical and laboratory standard institute (CLSI) M100-S22 guidelines. The Minimal Inhibitory Concentrations (MICs) of the carbapenem, ertapenem, imipenem and meropenem were determined for all the CRE’s by E-test. The isolates β-lactam resistance mechanisms were further investigated by analyzing 31 different types of β–lactamase genes by polymerase chain reaction (PCR). Results: Four bacterial isolates, 3 Enterobacter cloacae and 1 Klebsiella pneumoniae, were determined to be non-susceptible to one or all of the carbapenems (ertapenem, imipenem and meropenem) tested. All isolates which carried the blaKPC-2 gene showed an extreme drug resistance profile. These isolates were resistant to all β-lactam antibiotics, co-trimoxazole and gentamicin, while susceptible to only amikacin and colistin sulfate. Different combination of plasmid encoded b–lactamase genes (blaTEM, blaSHV, blaOXA-1, blaMIR-1, blaGES-23 and blaKPC-2) were present in these isolates. Of interest, was the isolation of the first E. cloacae strains co-producing the blaKPC-2 and a novel blaGES-23 β-lactamase. Conclusions: The presence of all these plasmid encoded b-lactamase in Palestine is alarming and mandates actions to be taken to control antibiotics usage and the activation of hospital infection control programs in order to prevent the spread of these extremely drug resistant bacteria

Evaluation of Meropenem, Imipenem and Ertapenem Impregnated MacConkey Agar Plates for the Detection of Carbapenem Resistant Enterobacteriaceae

Background: Rapid detection of carbapenem resistant bacteria, in particular, members of the Enterobacteriaceae family (CRE), is of utmost importance for the management of infected or colonized patients. Methods: Three carbapenems; meropenem, imipenem and ertapenem, with two different concentrations (0.5 mg/ml and 1.0 mg/ml), were impregnated in MacConkey agar. The carbapenem impregnated MacConkey agar plates; ([Mac-Mem], [Mac-Imp] and [Mac-Ert]), were then evaluated for the detection of carbapenem resistant Gram-negative bacteria in particular the blaKPC producing Enterobacteriaceae. The Limit of Detection (LOD) of the plates was determined after counting the colonies that grew on the plates after serial logarithmic dilutions of ten. Carbapenem resistant Gram-negative bacteria were prepared in normal saline, inoculated on the different plates and incubated at 35oC for 18-24 hours. The specificity and the shelf-life of the plates were determined by challenging the plates with six ESBL positive members of the Enterobacteriaceae family (K. pneumoniae, Salmonella species, Shigella species, E. coli, Proteus species and Citrobacter species) and one Enterobacter species with the blaAmpC phenotype. Finally, the MacConkey agar plates impregnated with 0.5 mg/ml meropenem were further challenged by incorporating them in the routine Caritas Baby Hospital active surveillance program for the detection of carbapenem resistant bacteria. Results: Of the three carbapenems impregnated plates, Mac-Ert plates gave the lowest number of colony forming units (CFU’s) detected regardless of the concentration of the antibiotic used. This was followed by the Mac-Mem plates which showed an LOD of less than 200 CFU’s for most of the blaKPC positive bacteria tested at both antibiotic concentrations. The worst performance was noted for the Mac-Imp plate regardless of the antibiotic concentration used as a number of carbapenem resistant bacterial strains failed to grow on the plate. The Mac-Mem plates showed the best specificity as none of the ESBL and blaAmpC positive isolates grew on the plates at either antibiotic concentration tested after 18-24hours incubation in ambient air at 35oC. On the other hand, the Mac-Ert plates failed to inhibit the growth of the Citrobacter species tested at both antibiotic concentrations and the Proteus species tested at the 0.5µg/ml antibiotic concentration. The Mac-Imp plates showed poor specificity as both concentrations failed to inhibit the growth of the Proteus, Enterobacter and Citrobacter species evaluated after 18-24 hours incubation in ambient air at 35oC. Of all the plates tested, the 0.5 µg/ml Mac-Mem agar had the best shelf-life of up to one month at 4-8oC. Conclusions: The high specificity and the good selectivity, in addition to the long shelf-life allowed the 0.5µg/ml Mac-Mem agar to be used as a cost effective selective medium for the isolation of carbapenem resistant Gram-negative bacteria, in particular the blaKPC producing members of the Enterobacteriaceae family

Increase Human Metapneumovirus Mediated Morbidity following Pandemic Influenza Infection

Human metapneumovirus (hMPV) is a recently discovered respiratory pathogen, infecting mainly young children. The infected patients suffer from influenza like symptoms (ILS). In Israel the virus is mainly circulating in February to March. Here we report on an increased rate of hMPV infection in the winter season of 2009–10. The 2009–10 infection had several unique characteristics when compared to previous seasons; it started around January and a large number of infants were infected by the virus. Genetic analysis based on the viral L and F genes of hMPV showed that only subtypes A2 and B2 circulated in Israel. Additionally, we have identified a novel variant of hMPV within subgroup A2b, which subdivide it into A2b1 and A2b2. Finally, we showed that the hMPV infection was detected in the country soon after the infection with the pandemic influenza virus had declined, that infection with the pandemic influenza virus was dominant and that it interfered with the infection of other respiratory viruses. Thus, we suggest that the unusual increase in hMPV infection observed in 2009–10 was due to the appearance of the pandemic influenza virus in the winter season prior to 2009–10

Serotype Distribution and Drug Resistance in Streptococcus pneumoniae, Palestinian Territories

To determine antimicrobial drug resistance of Streptococcus pneumoniae serotypes, we analyzed isolates from blood cultures of sick children residing in the West Bank before initiation of pneumococcal vaccination. Of 120 serotypes isolated, 50.8%, 73.3%, and 80.8% of the bacteremia cases could have been prevented by pneumococcal conjugate vaccines. Serotype 14 was the most drug-resistant serotype isolated

Comparison of Three Transport Systems (Starplex StarSwab II, the New Copan Vi-Pak Amies Agar Gel Collection and Transport Swabs, and BBL Port-A-Cul) for Maintenance of Anaerobic and Fastidious Aerobic Organisms

Of utmost importance in evaluations of clinical samples for infectious agents is proper specimen transport to the clinical laboratory. In the present study we compared three transport systems (the new Starplex StarSwab II, the new Copan Vi-Pak Amies Agar Gel collection and transport swabs, and the BBL Port-A-Cul) for survival of anaerobic and fastidious aerobic bacteria. The new Copan Vi-Pak system has been modified by nitrogen gas flushing to keep an ideal low E(h) condition and to prevent oxidation of the transport medium. The Copan Vi-Pak system outperformed the other two swabs evaluated by maintaining the viabilities of both anaerobic and fastidious aerobic bacteria for 24 h for the majority of the organisms evaluated. This time period should be sufficient for transport of specimens to the clinical microbiology laboratory without compromising organism recovery