Sunday, July 22, 2007


Turtle-associated salmonellosis in humans--United States, 2006-2007

Turtle-associated salmonellosis in humans--United States, 2006-2007

MMWR Morb Mortal Wkly Rep. 2007 Jul

Centers for Disease Control and Prevention (CDC).

Turtles and other reptiles are reservoirs of Salmonella and have long been a recognized source of Salmonella infection in humans. Small turtles have posed a particular danger to young children because these turtles might not be perceived as health hazards and can be handled like toys. Salmonella infections in children can be severe and can result in hospitalization and occasionally in death.

The association between Salmonella infection in children and exposure to turtles led to a 1975 law prohibiting the sale or distribution of small turtles (i.e., those with a carapace of <4>

This report describes several recent cases of turtle-associated salmonellosis reported to CDC by state and local health departments since September 2006, including a fatal case in an infant. These cases illustrate that small turtles remain a source of human Salmonella infections. Although ongoing public education measures aimed at preventing reptile-acquired Salmonella infections are helpful, prohibiting the sale of small turtles likely remains the most effective public health action to prevent turtle-associated salmonellosis.

Salmonella Pomona Infections --- Multiple States

On February 20, 2007, a female infant aged 3 weeks with a 1-day history of poor feeding and lethargy was evaluated in an emergency department at a Florida hospital. The patient was transferred immediately to a tertiary-care pediatric hospital; on arrival, she was febrile and in septic shock. Antibiotics were administered. She died on March 1. Cultures of cerebrospinal fluid and blood samples yielded Salmonella serotype Pomona.

The parents of the patient were interviewed by the Florida Department of Health. A family friend had purchased a small turtle with a carapace of 1.25 inches from a flea market in north central Florida in mid-November 2006. The turtle was purchased as a pet and given to the patient's family in late January 2007. After the death of the infant, laboratory testing of the turtle and its environment was performed by the Florida Bureau of Laboratories. A fecal sample from the turtle yielded S. Pomona. The S. Pomona isolates from the patient and the turtle were indistinguishable by pulsed-field gel electrophoresis (PFGE).

A total of 19 other S. Pomona isolates from 19 patients in 11 states (Alabama, Arizona, California, Florida, Massachusetts, Nevada, New Mexico, New York, Pennsylvania, South Carolina, and Texas) with a PFGE pattern closely related to the isolate from the Florida patient and turtle were submitted to PulseNet,* with isolation dates ranging from October 2, 2006 to April 23, 2007. To determine whether these cases of S. Pomona infection were associated with turtle exposure, CDC staff, through OutbreakNet,† coordinated an investigation with state and city health departments, which conducted interviews with patients or their parents or guardians. The median age of patients was 3 years (range: 2 months--59 years). Illness onsets occurred during September 30, 2006--April 23, 2007. Of the 15 interviewed patients, 12 (80%) had direct or indirect contact with a turtle within 7 days before illness onset. Among those 12 patients, nine (75%) had turtles as household pets. The duration of turtle ownership before illness onset ranged from <1>

Salmonella I 4,[5],12:i:- Infections --- Ohio and Tennessee

Ohio. In September 2006, a previously healthy boy aged 8 years had onset of bloody diarrhea with cramping, headache, vomiting, and fever of 101.0°F (38.3°C). The Ohio Department of Health Laboratory isolated Salmonella I 4,[5],12:i:- from a stool specimen. The patient recovered at home after 3 days. No family member reported a similar illness while the patient was ill. However, the next month, the patient's brother, aged 12 years, had onset of bloody diarrhea; a stool specimen yielded Salmonella I 4,[5],12:i:-.

Two weeks before the first patient became ill, the family had purchased three red-eared slider turtles as pets, each with a carapace of <4>

County health officials visited the patient's home and collected a stool specimen from the child, an external surface swab from both turtles, and a water sample from the aquarium. Specimens from the child and turtles yielded Salmonella I 4,[5],12:i:- isolates, which were indistinguishable from the mother's isolate based on PFGE performed at the Tennessee Department of Health Laboratory. The aquarium water sample yielded Salmonella Pomona.

Reported by: D Chatfield, MSEH, Clark County Combined Health District; K Winpisinger, MS, Ohio Dept of Health. P Sumner, N Grossman, MD, Marion County Health Dept; R Hammond, PhD, D Windham, P Fiorella, PhD, Florida Dept of Health. ME Ress, Sullivan County Regional Health Dept; H Hardin, MPA, Tennessee Dept of Health Laboratory Svcs; J Dunn, DVM, Tennessee Dept of Health. M Iwamoto, MD, T-A Nguyen, MPH, N Patel, J Lockett, M Sotir, PhD, Div of Foodborne, Bacterial, and Mycotic Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases, CDC.

Editorial Note:

Despite a federal law prohibiting the sale or distribution of small turtles as pets, such sales still occur. Salmonella can be transmitted to humans by direct or indirect contact with a turtle or its feces. No reliable methods are available to guarantee that a turtle is free of Salmonella. Most turtles are colonized with Salmonella and shed the bacteria intermittently in their feces.

Certain techniques to eliminate Salmonella from turtles have been unsuccessful and have resulted in Salmonella isolates with increased antibiotic resistance (7). In addition, turtles not shedding Salmonella species under normal circumstances have been shown to actively shed the bacteria when stressed (8). Moreover, water in turtle bowls or aquariums can amplify any Salmonella shed by turtles. For these reasons, all turtles, regardless of carapace size, should be handled as though they are infected with Salmonella.

In 1980, CDC estimated that the 1975 federal prohibition of the sale of small turtles in the United States had prevented an estimated 100,000 cases of turtle-associated salmonellosis in children aged 1--9 years in 1976 (4). These additional cases might have resulted in approximately 1,500 hospitalizations and 40 deaths that year (4--6). Reductions in human illnesses associated with turtle-associated Salmonella strains were observed in other countries when similar small turtle sale prohibitions were enacted (9,10). When Sweden joined the European Union in 1996 and sale prohibitions were repealed, the number of human salmonellosis cases from reptile-associated Salmonella strains increased substantially, with children being most affected (9).

Centers for Disease Control


Sunday, July 15, 2007


Bacteria and Bacterial Infections in Public Pools

Bacteria and Bacterial Infections in Public Pools
Swimming in bacteria? What's lurking in the pool CBC News Online

On a hot summer day, taking a dip in the pool is a refreshing escape from the heat. But "fresh" might not be the right word if your swimming companions include bacteria that can cause vomiting, diarrhea and skin disease.

On Aug. 22, Quebec Environment Minister Claude Béchard announced all public pools in the province would be tested for chlorine and acid levels every three hours. Tests for bacteria levels would be done twice a month.

The new rules will come into effect in the coming months. Earlier in the week, lab tests showed outdoor swimming pools in Montreal and Laval, north of Montreal, were heavily contaminated with bacteria, viruses and fecal matter.

Test results must be submitted to the provincial government, Béchard said. Municipalities are responsible for pool safety in Quebec, but the province has the power to close facilities.

Elsewhere in Canada, documents obtained by CBC News showed that Winnipeg's environmental health inspectors shut down 13 pools and whirlpools in 2004 because of bacteria contamination, chlorine imbalance or unsafe conditions. And in Nova Scotia in 2003, a former public health officer sampled water in 19 public swimming pools and found unacceptably high levels of bacteria. The results failed to meet provincial guidelines.

It's a scary prospect that the local swimming pool could be a veritable microbial soup, bubbling with germs and parasites.

Where do the organisms come from?

The risk of illness and infection from swimming pools derives mostly from fecal contamination of the water. Vomit, mucus, saliva and skin are also sources of dangerous germs in the pool.

Sometimes these substances are released into the water by bathers, or they can come directly from birds and rodents. Viral outbreaks can also come from inadequate pool sanitation. Filtering the pool water and adding chlorine, salt and other disinfectants will usually control harmful germs in the water.

Gary Sanger, aquatics supervisor for the City of Toronto, says the city has a detailed process to keep the pools contaminant free. Pool officials test the water a half hour before a pool is open to the public, and every two hours thereafter. If there are any foreign substances such as vomit in the water, Sanger says, the pool is closed for cleaning and chlorination.

During the summer it becomes more difficult to control the bacteria, says Dr. John Carsley of the Montreal Public Health Department.

"It's a challenge to keep the chlorine at the right level, from what I understand," Carsley said. "Especially, the hotter it gets, the quicker the chlorine gets used up."

The more swimmers splashing in the water, the harder it is to maintain the appropriate levels of chlorine to keep the germs at bay. "The more people who get in the pool and the more demand in terms of microbial burden there is," he says.

The hotter the water the temperature, the better the habitat for bacteria. Hot tubs and natural spas with mineral water are an ideal breeding ground for germs such as legionella.

What kind of illnesses can I catch from swimming in a contaminated pool?

E.coli can lead to bloody diarrhea, as well as vomiting and fever in more severe cases. Elderly people and infants can develop haemolytic uraemic syndrome (HUS), which can lead to kidney failure. Shigella bacteria can cause diarrhea, fever and nausea.

Illnesses can also stem from parasites found in fecal matter in the water. The most common are Giardia and Cryptosporidium, or C. difficile, according to the World Health Organization. They are both highly contagious because infected individuals shed the sickness-causing germs in large amounts. Giardiasis is characterized by diarrhea, cramps, foul-smelling stools, loss of appetite, fatigue and vomiting. Symptoms of cryptosporidiosis include diarrhea, vomiting, fever and abdominal cramps.

It is difficult to directly link outbreaks of illness with pool water because the evidence is usually circumstantial, according to the WHO, such as a pattern between swimmers' symptoms and where they last swam. It's difficult to isolate these microbes from the water itself.

Are there pool sanitation regulations to control the bacteria levels in public pools?

There aren't nation-wide regulations for pool sanitation in Canada, but each province has its own set. They typically include testing the bacteria levels in the pool before opening it to the public, testing it regularly while people are swimming, and cleaning and disinfecting the pool regularly.

The World Health Organization also has a set of recommended guidelines for safe swimming.

What can I do to have a healthy and safe swim?

Both pool and swimmers have their part to play, Sanger says. Pool officials can control the contamination of pools by encouraging swimmers to shower before diving in, he says.

Sanger encourages parents to bathe their kids before bringing them into the pool. And he advises young children use disposable swim trunks designed to keep unwanted substances under wraps.

The World Health Organization recommends keeping small children in pools small enough to drain, in the event of accidental defecation.

As well, people with gastroenteritis — inflammation of the gastrointestinal tract or the pathway responsible for digestion including the mouth, esophagus, stomach and intestines, also known as the "stomach flu" — should not go to public or semi-public pools until at least a week after their illness.


The Hidden Dangers of Public Pools

Summertime is here and everyone is ready to hit the public pool in an attempt to beat the heat. What many people don't realize is that their local pool might not be as safe as they assume. Here's a look at some of the most common dangers you and your family face when swimming in public waters. As much as we would like to think that the chlorine in the pool kills everything off, it might not be true. Bacteria and viruses can really thrive in a moist area like a pool and the area surrounding it. A pool must be very carefully maintained in order to keep harmful germs at bay and many pools simply lack the high standards that are necessary. Also, if too many people are using the pool at once, the chemicals in the water may not have a chance to kill everything off before others are infected.

Any kind of infection can be spread in the water. A swimmer suffering from a stomach problem will have the bacteria or virus on their skin and this is easily washed into the water, to be accidentally ingested by another person. This is particularly true where small children swim. Swim diapers don't hold everything in and even changing a diaper near the pool can result in bacteria getting into the water.

Certain types of bacteria, known as "crypto", are able to survive for long periods of time in the water, even well-chlorinated water. Others take up to an hour or two to die off, which leaves plenty of time to infect other people who are swimming in the pool. Viruses can usually survive for quite a bit more time. Chlorine and other pool chemicals are not a guarantee against contracting a disease while swimming in public areas.

The dangers of public pools don't end in the water. The dressing rooms can harbor mold which may cause respiratory problems in those who are sensitive to this sort of thing. The constant dampness harbors bacteria such as athlete's foot and the like.

To keep yourself and your kids safe, avoid wading pools where contamination is more likely. Ask about the pool maintainance schedule and how often the chlorine levels are tested. You might also want to take your family swimming on days when there are fewer people in the pool and avoid contributing to the problem by keeping sick kids out of the water. Also, try not to let any water get in your mouth, since this is how most bacteria and viruses get into the body.

In the dressing room, don't toss towels on the floor and then use them to dry off. Wearing flip flops or water shoes is a good way to avoid athlete's foot and other fungi that might cause problems, take them off poolside.

While pools can be a fun way to cool off, it pays to remember that they are the perfect place for germs, viruses and bacteria to grow. Play it safe and take the precautions listed above.


Shigella: A Bacterial Infection on the Rise This Summer Health Depts. Say to Use Special Care Over Fourth of July Holiday By Sussy Published Jul 03, 2007



Pseudomonas bacteria contamination is an emerging health concern that most pool and spa companies are unaware of, and most water testing performed by these companies do not check for bacteria contamination. "Hot tub rash" is many times incorrectly attributed to too much chlorine in the water when many times the culprit is actually Pseudomonas bacteria contamination. Cutting back on chlorine in these situations actually exacerbates the problem.

What is it?

Pseudomonas species are opportunistic pathogens that are part of the normal bacterial flora of the pharynx, mucous membranes and skin of humans. It flourishes in warm, moist areas which makes pools and hot tubs an ideal environment for this bacteria. In recent years the number of reported Pseudomonas outbreaks in recreational waters has risen dramatically. Pseudomonas is capable of causing significant illnesses including skin rashes (folliculitis), ear infections (swimmer’s ear), urinary tract infections, pneumonia and corneal ulcers (keratitis).

Why is it important?

Pseudomonas is a very virulent opportunistic pathogen and is becoming increasingly resistant to antibiotics. It is the most commonly isolated bacteria from skin rashes and ear infections associated with recreational waters.

Otitis externa, commonly known as "swimmer’s ear", is caused mainly by the species Pseudomonas aeruginosa. Symptoms include redness and swelling of the ear canal, itching, fluid leakage and severe pain. Pseudomonas frequently causes skin infections (folliculitis) involving a mild to moderate red, itchy rash. These rashes are often mistaken for chicken pox. The bacteria is also a significant contributor to urinary tract infections as well as secondary infections in hospitalized patients. Pseudomonas aeruginosa is one of the leading (and most damaging) causative agents of microbial keratitis in contact lens wearers. This bacteria is of major concern in hospitals, since it can cause severe secondary infections, such as pneumonia, in burn victims or immunocompromised persons.

In rare circumstances, Pseudomonas can cause more serious infections. In diabetic, elderly or immunocompromised persons, a life threatening condition known as malignant otitis externa could occur. The bacteria in the ear spreads to the surrounding tissue and bone potentially leading to muscle paralysis, meningitis or brain abscesses. In severe cases of microbial keratitis, the lesions on the cornea can ulcerate within 24-48 hours. Blindness can occur rapidly due to destruction of the interior eye structures.

Where is Pseudomonas?

Pseudomonas is commonly isolated from water and soil. It is normally found in low quantities in the pharynx, skin and mucous membranes of normal healthy persons. It proliferates in wet or moist areas, particularly pools and hot tubs and surrounding carpeted areas. Any recreational waters which have multiple users, such as public pools, are also possible sources of the bacteria. Inside the home, handtowels and sinktraps, are the areas most likely to contain Pseudomonas. This bacteria is of major concern in hospitals, since it has been indicated in secondary infections.

How do you get Pseudomonas?

Most hot tub mediated infections occur due to improper water maintenance or exceeding the maximum carrying capacity of the water. For example, when several bathers are in a small amount of water, the amount of water per person decreases. The disinfectants in the water are used up on the excessive amount of bacteria and debris supplied by each person so any remaining bacteria, such as Pseudomonas, will not be eliminated. When a person’s skin is heated, the follicles expand allowing the Pseudomonas bacteria to enter through the pores. Folliculitis, the most common result of this type of infection, is a mild to moderate skin rash. Swimmer’s ear occurs when the ear canal becomes sufficiently moist, usually while swimming, allowing the bacteria the opportunity to breed. They begin to colonize the canal and cause extreme discomfort, redness and swelling. Urinary tract infections are also regularly associated with Pseudomonas infections. In hospitals, Pseudomonas aeruginosa can infect persons with weakened immune systems, it can colonize catheters as well as therapeutic whirlpools.

When contact lens hardware or cleansing solution becomes contaminated, the risk for developing microbial keratitis is greatly increased. Since Pseudomonas is a normal inhabitant of the skin, the bacteria can be passed directly from the skin to the contact lens. It can also be transferred to handtowels, which when reused would transfer the bacteria back to the hands. Studies show that Pseudomonas is capable of surviving in many commercial saline solutions, in which case, contaminated lenses would not be properly cleansed by saline solution alone. Exceeding the recommended wear time of contact lenses has been reported as probably being the largest contributor to microbial keratitis. Pseudomonas aeruginosa has several structural and chemical components that make it especially adept at adhering to the corneal surface of the eye. Over wear of lenses weakens the eye’s defenses and makes the cornea more susceptible to bacterial infection and damage.

What should you do about it?

If you own a pool or a hot tub testing should be done to ensure that the bacteria is not present in your system. If Pseudomonas is detected, the extent to which it is present should be determined. Proper steps should be incurred to remove the bacteria. The rashes associated with
Pseudomonas bacteria are often attributed to excess chlorination so people tend to under chlorinate their pools and hot tubs. Pseudomonas folliculitis and urinary tract infections can sometimes be avoided by bathing after swimming, removing wet swimsuits immediately, and avoiding public pools with multiple swimmers.

Proper pH of the water and attentive maintenance is vital to prevent Pseudomonas from establishing itself in your pool or hot tub. If Pseudomonas is left untreated, the bacteria will cover itself in a protective slime layer which is resistant to chlorine. It will then colonize your pool or hot tub, which is characterized by a slimy layer on the sides of the pool particularly in low flow areas. When this happens, the removal of the bacteria is much more difficult. The pool or spa may have to be drained and scrubbed. A professional should be consulted.

Indicators that Pseudomonas may be present in your pool are visible signs of the bacteria, frequent occurrences of swimmer’s ear, skin rashes, urinary tract infections etc. in you or your family members.

An ophthalmologist should be consulted in all cases of eye infections. Proper contact lens wear and maintenance is strongly recommended to avoid Pseudomonas corneal infections. Non-clinical surface samples (i.e. sinks, drains, carpet by pool areas) may be taken and analyzed by a laboratory to determine the source of the bacteria. Medical questions or concerns should be directed towards your ophthalmologist or physician.


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Friday, July 06, 2007


Clostridium difficile: changing epidemiology and new treatment options.

Clostridium difficile: changing epidemiology and new treatment options.

Curr Opin Infect Dis. 2007 Aug

Kuijper EJ, van Dissel JT, Wilcox MH.
aDepartment of Medical Microbiology, Leiden University Medical Center, Leiden, the Netherlands bInfectious Diseases, Leiden University Medical Center, Leiden, the Netherlands cDepartment of Medical Microbiology, Leeds Teaching Hospitals and University of Leeds, Leeds, UK.

PURPOSE OF REVIEW: The review summarizes changes in the epidemiology and treatment of Clostridium difficile-associated disease.

RECENT FINDINGS: Recent outbreaks of Clostridrium difficile-associated diarrhoea with increased severity, high relapse rate and significant mortality, have been related to the emergence of a new, hypervirulent C. difficile strain in north America, Japan and Europe. Definitions have been proposed by the European Centre for Disease Prevention and Control to identify severe cases of Clostridrium difficile-associated diarrhoea and to differentiate community-acquired cases from nosocomial-acquired cases. The emerging strain is referred to as North American pulsed-field type 1 and polymerase chain reaction ribotype 027. The emerging strain has also been detected in calf diarrhoea and ground meat samples in Canada.

Attempts to prevent outbreaks caused by type 027 should focus on controlling the overall use of antibiotics, and high-risk antibiotics such as cephalosporins, clindamycin and fluoroquinolones. Several new antibiotic and non-antibiotic alternatives have become available; there is currently no place for probiotic treatments. Patients who suffer multiple relapses of C. difficile-associated diarrhoea present a major therapeutic challenge.

SUMMARY: The early recognition of Clostridrium difficile-associated diarrhoea caused by NAP1/027 is necessary to start rapid treatment, to prevent complications, and to prevent further spread of the bacterium.

Lippincott, Williams & Wilkins

A portrait of the geographic dissemination of the Clostridium difficile North American pulsed-field type 1 strain and the epidemiology of C. difficile-associated disease in Québec.

Clin Infect Dis. 2007 * Full Text Article

Hubert B, Loo VG, Bourgault AM, Poirier L, Dascal A, Fortin E, Dionne M, Lorange M.
Institut National de Santé Publique du Québec, Québec, Canada.

BACKGROUND: An increase in the incidence and severity of Clostridium difficile-associated disease in Québec and the United States has been associated with a hypervirulent strain referred to as North American pulsed-field type 1 (NAP1)/027.

METHODS: In 2005, a prospective study was conducted in 88 Québec hospitals, and 478 consecutive nosocomial isolates of C. difficile were obtained. The isolates were subjected to pulsed-field gel electrophoresis (PFGE) typing, antimicrobial susceptibility testing, and detection of binary toxin genes and tcdC gene deletion. Data on patient age and occurrence of complications were collected.

RESULTS: PFGE typing of 478 isolates of C. difficile yielded 61 PFGE profiles. Pulsovars A (57%), B (10%), and B1 (8%) were predominant. The PFGE profile of pulsovar A was identical to that of strain NAP1. It showed 67% relatedness with 15 other PFGE patterns, among which 11 had both binary toxin genes and a partial tcdC deletion but different antibiotic susceptibility profiles. Pulsovars B and B1 were identical to strain NAP2/ribotype 001. In hospitals showing a predominant clonal A or B-B1 PFGE pattern, incidence of C. difficile-associated disease was 2 and 1.3 times higher, respectively, than in hospitals without any predominant clonal PFGE pattern. Severe disease was twice as frequent among patients with strains possessing binary toxin genes and tcdC deletion than among patients with strains lacking these virulence factors.

CONCLUSIONS: This study helped to quantify the impact of strain NAP1 on the incidence and severity of C. difficile-associated disease in Québec in 2005. The identification of the geographic dissemination of this predominant strain may help to focus regional infection-control efforts.

University of Chicago Press * Full Text Article

Implications of the changing face of Clostridium difficile disease for health care practitioners.

Am J Infect Control. 2007 May

McFarland LV, Beneda HW, Clarridge JE, Raugi GJ.

From the Department of Health Services Research and Development, Veterans Administration Puget Sound Health Care System, Seattle, WA 98101, USA.

Recent reported outbreaks of Clostridium difficile-associated disease in Canada have changed the profile of C difficile infections.

Historically, C difficile disease was thought of mainly as a nosocomial disease associated with broad-spectrum antibiotics, and the disease was usually not life threatening. The emergence of an epidemic strain, BI/NAP1/027, which produces a binary toxin in addition to the 2 classic C difficile toxins A and B and is resistant to some fluoroquinolones, was associated with large numbers of cases with high rates of mortality.

Recently, C difficile has been reported more frequently in nonhospital-based settings, such as community-acquired cases. The C difficile disease is also being reported in populations once considered of low risk (children and young healthy women). In addition, poor response to metronidazole treatment is increasing. Faced with an increasing incidence of C difficile infections and the changing profile of patients who become infected, this paper will reexamine the current concepts on the epidemiology and treatment of C difficile-associated disease, present new hypotheses for risk factors, examine the role of spores in the transmission of C difficile, and provide recommendations that may enhance infection control practices.


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