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Acute bacterial, nonnecrotizing cellulitis in Finland: microbiological findings.

https://arctichealth.org/en/permalink/ahliterature158912
Source
Clin Infect Dis. 2008 Mar 15;46(6):855-61
Publication Type
Article
Date
Mar-15-2008
Author
Tuula Siljander
Matti Karppelin
Susanna Vähäkuopus
Jaana Syrjänen
Maija Toropainen
Juha Kere
Risto Vuento
Tapio Jussila
Jaana Vuopio-Varkila
Author Affiliation
Department of Bacterial and Inflammatory Diseases, National Public Health Institute, Helsinki, Finland. tuula.siljander@ktl.fi
Source
Clin Infect Dis. 2008 Mar 15;46(6):855-61
Date
Mar-15-2008
Language
English
Publication Type
Article
Keywords
Acute Disease
Adult
Aged
Aged, 80 and over
Blood - microbiology
Carrier State - microbiology
Case-Control Studies
Cellulitis - epidemiology - microbiology
Culture Media
Electrophoresis, Gel, Pulsed-Field
Family Characteristics
Female
Finland - epidemiology
Humans
Male
Middle Aged
Pharynx - microbiology
Streptococcal Infections - epidemiology - microbiology
Streptococcus - classification - genetics - isolation & purification
Abstract
Bacterial, nonnecrotizing cellulitis is a localized and often recurrent infection of the skin. The aim of this study was to identify the beta-hemolytic streptococci that cause acute nonnecrotizing cellulitis infection in Finland.
A case-control study of 90 patients hospitalized for acute cellulitis and 90 control subjects was conducted during the period of April 2004-March 2005. Bacterial swab samples were obtained from skin lesions or any abrasion or fissured toe web. Blood culture samples were taken for detection of bacteremia. The patients, their household members, and control subjects were assessed for pharyngeal carrier status. beta-Hemolytic streptococci and Staphylococcus aureus were isolated and identified, and group A and G streptococcal isolates were further analyzed by T serotyping and emm and pulsed-field gel electrophoresis typing.
beta-Hemolytic streptococci were isolated from 26 (29%) of 90 patients, 2 isolates of which were blood-culture positive for group G streptococci, and 24 patients had culture-positive skin lesions. Group G Streptococcus (Streptococcus dysgalactiae subsp. equisimilis) was found most often and was isolated from 22% of patient samples of either skin lesions or blood, followed by group A Streptococcus, which was found in 7% of patients. Group G streptococci were also carried in the pharynx of 7% of patients and 13% of household members but was missing from control subjects. Several emm and pulsed-field gel electrophoresis types were present among the isolates. Six patients (7%) had recurrent infections during the study. In 2 patients, the group G streptococcal isolates recovered from skin lesions during 2 consecutive episodes had identical emm and pulsed-field gel electrophoresis types.
Group G streptococci, instead of group A streptococci, predominated in bacterial cellulitis. No clear predominance of a specific emm type was seen. The recurrent nature of cellulitis became evident during this study.
PubMed ID
18260753 View in PubMed
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Adapting spa typing for national laboratory-based surveillance of methicillin-resistant Staphylococcus aureus.

https://arctichealth.org/en/permalink/ahliterature137554
Source
Eur J Clin Microbiol Infect Dis. 2011 Jun;30(6):789-97
Publication Type
Article
Date
Jun-2011
Author
A. Vainio
S. Koskela
A. Virolainen
J. Vuopio
S. Salmenlinna
Author Affiliation
Department of Infectious Disease Surveillance and Control, National Institute for Health and Welfare (THL), PO Box 30, 00271 Helsinki, Finland. anni.vainio@thl.fi
Source
Eur J Clin Microbiol Infect Dis. 2011 Jun;30(6):789-97
Date
Jun-2011
Language
English
Publication Type
Article
Keywords
Bacteremia - microbiology
Bacterial Typing Techniques - economics - methods
Cluster analysis
Electrophoresis, Gel, Pulsed-Field
Finland
Genotype
Humans
Methicillin-Resistant Staphylococcus aureus - classification - genetics - isolation & purification
Molecular Epidemiology - methods
Molecular Typing - economics - methods
Staphylococcal Infections - microbiology
Time Factors
Abstract
Laboratory-based surveillance of methicillin-resistant Staphylococcus aureus (MRSA) monitors the baseline occurrence of different genotypes and identifies strains and transmission chains responsible for outbreaks. The consequences of substituting pulsed-field gel electrophoresis (PFGE) with spa typing as a first-line typing method were analyzed by typing 589 strains isolated between 1997 and 2006, with a focus on both short- and long-term correspondence between the PFGE and spa typing results. The study, covering these ten years, included all Finnish MRSA blood isolates and representatives of the two most prevalent MRSA strains (PFGE types FIN-4 and FIN-16) in Finland. In addition, all sporadic isolates from 2006 were included. spa typing was more expensive but approximately four times faster to perform than PFGE. Nearly 90% of FIN-4 and FIN-16 isolates showed consistent spa types, t172 and t067, respectively. spa typing predicted the PFGE result of the blood isolates by a Wallace coefficient of 0.9009, recognized internationally successful strains (t041, t067) to be common also in Finland, and identified a separate cluster of isolates, also related in time and place among the FIN-4 strains. Additional typing by another method was needed to provide adequate discrimination or to characterize isolates with a newly recognized spa type in Finland.
PubMed ID
21271269 View in PubMed
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Agricultural, socioeconomic and environmental variables as risks for human verotoxigenic Escherichia coli (VTEC) infection in Finland.

https://arctichealth.org/en/permalink/ahliterature130372
Source
BMC Infect Dis. 2011;11:275
Publication Type
Article
Date
2011
Author
Katri Jalava
Jukka Ollgren
Marjut Eklund
Anja Siitonen
Markku Kuusi
Author Affiliation
Department of Infectious Disease Surveillance and Control, National Institute for Health and Welfare, Helsinki, Finland. katri.jalava@thl.fi
Source
BMC Infect Dis. 2011;11:275
Date
2011
Language
English
Publication Type
Article
Keywords
Adult
Aged
Aged, 80 and over
Child
Child, Preschool
Electrophoresis, Gel, Pulsed-Field
Environmental Exposure
Escherichia coli Infections - epidemiology - microbiology
Female
Finland - epidemiology
Humans
Incidence
Infant
Male
Middle Aged
Models, Statistical
Molecular Typing
Risk factors
Shiga-Toxigenic Escherichia coli - classification - genetics - isolation & purification
Socioeconomic Factors
Virulence Factors - genetics
Abstract
Verotoxigenic E. coli (VTEC) is the cause of severe gastrointestinal infection especially among infants. Between 10 and 20 cases are reported annually to the National Infectious Disease Register (NIDR) in Finland. The aim of this study was to identify explanatory variables for VTEC infections reported to the NIDR in Finland between 1997 and 2006. We applied a hurdle model, applicable for a dataset with an excess of zeros.
We enrolled 131 domestically acquired primary cases of VTEC between 1997 and 2006 from routine surveillance data. The isolated strains were characterized by virulence type, serogroup, phage type and pulsed-field gel electrophoresis. By applying a two-part Bayesian hurdle model to infectious disease surveillance data, we were able to create a model in which the covariates were associated with the probability for occurrence of the cases in the logistic regression part and the magnitude of covariate changes in the Poisson regression part if cases do occur. The model also included spatial correlations between neighbouring municipalities.
The average annual incidence rate was 4.8 cases per million inhabitants based on the cases as reported to the NIDR. Of the 131 cases, 74 VTEC O157 and 58 non-O157 strains were isolated (one person had dual infections). The number of bulls per human population and the proportion of the population with a higher education were associated with an increased occurrence and incidence of human VTEC infections in 70 (17%) of 416 of Finnish municipalities. In addition, the proportion of fresh water per area, the proportion of cultivated land per area and the proportion of low income households with children were associated with increased incidence of VTEC infections.
With hurdle models we were able to distinguish between risk factors for the occurrence of the disease and the incidence of the disease for data characterised by an excess of zeros. The density of bulls and the proportion of the population with higher education were significant both for occurrence and incidence, while the proportion of fresh water, cultivated land, and the proportion of low income households with children were significant for the incidence of the disease.
Notes
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PubMed ID
22008456 View in PubMed
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Ambler class A extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella spp. in Canadian hospitals.

https://arctichealth.org/en/permalink/ahliterature180913
Source
Antimicrob Agents Chemother. 2004 Apr;48(4):1204-14
Publication Type
Article
Date
Apr-2004
Author
Michael R Mulvey
Elizabeth Bryce
David Boyd
Marianna Ofner-Agostini
Sara Christianson
Andrew E Simor
Shirley Paton
Author Affiliation
Nosocomial Infections, National Microbiology Laboratory, Health Canada, Winnipeg, Manitoba. michael_mulvey@hc-sc.gc.ca
Source
Antimicrob Agents Chemother. 2004 Apr;48(4):1204-14
Date
Apr-2004
Language
English
Publication Type
Article
Keywords
Anti-Bacterial Agents - pharmacology
Canada - epidemiology
Chromosome Mapping
Drug Resistance, Bacterial
Electrophoresis, Gel, Pulsed-Field
Escherichia coli - drug effects - enzymology
Escherichia coli Infections - epidemiology - microbiology
Humans
Klebsiella - drug effects - enzymology
Klebsiella Infections - epidemiology - microbiology
Microbial Sensitivity Tests
Molecular Sequence Data
Phenotype
Plasmids - genetics
Population Surveillance
Prospective Studies
Reverse Transcriptase Polymerase Chain Reaction
Transformation, Bacterial - genetics
beta-Lactamases - biosynthesis - genetics
Abstract
This report describes a study carried out to gain baseline information on the molecular characteristics of extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella spp. in Canada. A total of 29,323 E. coli and 5,156 Klebsiella sp. isolates were screened at 12 participating sites. Of these, 505 clinically significant, nonrepeat isolates displaying reduced susceptibility to the NCCLS-recommended beta-lactams were submitted to a central laboratory over a 1-year period ending on 30 September 2000. A total of 116 isolates were confirmed to be ESBL producers. PCR and sequence analysis revealed the presence of TEM-11 (n = 1), TEM-12 (n = 1), TEM-29 (n = 1), TEM-52 (n = 4), CTX-M-13 (n = 1), CTX-M-14 (n = 15), CTX-M-15 (n = 11), SHV-2 (n = 2), SHV-2a (n = 12), SHV-5 (n = 6), SHV-12 (n = 45), and SHV-30 (n = 2). Five novel beta-lactamases were identified and designated TEM-115 (n = 2), TEM-120 (n = 1), SHV-40 (n = 2), SHV-41 (n = 4), and SHV-42 (n = 1). In addition, no molecular mechanism was identified for five isolates displaying an ESBL phenotype. Macrorestriction analysis of all ESBL isolates was conducted, as was restriction fragment length polymorphism analysis of plasmids harboring ESBLs. Although a "clonal" distribution of isolates was observed at some individual sites, there was very little evidence suggesting intrahospital spread. In addition, examples of identical or closely related plasmids that were identified at geographically distinct sites across Canada are given. However, there was considerable diversity with respect to plasmid types observed.
Notes
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PubMed ID
15047521 View in PubMed
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Ampicillin-resistant enterococci in a Swedish university hospital: nosocomial spread and risk factors for infection.

https://arctichealth.org/en/permalink/ahliterature195013
Source
Scand J Infect Dis. 2001;33(3):182-7
Publication Type
Article
Date
2001
Author
E. Torell
O. Cars
A. Hambraeus
Author Affiliation
Department of Medical Sciences, Uppsala University Hospital, Sweden.
Source
Scand J Infect Dis. 2001;33(3):182-7
Date
2001
Language
English
Publication Type
Article
Keywords
Ampicillin Resistance
Anti-Bacterial Agents - therapeutic use
Carrier State - epidemiology - microbiology - transmission
Case-Control Studies
Cross Infection - epidemiology - microbiology - transmission
Drug Resistance, Microbial
Electrophoresis, Gel, Pulsed-Field
Enterococcus - classification - drug effects - isolation & purification
Feces - microbiology
Female
Gram-Positive Bacterial Infections - epidemiology - microbiology - transmission
Humans
Incidence
Infection Control
Longevity
Male
Odds Ratio
Risk factors
Sweden - epidemiology
Time Factors
Abstract
Ampicillin-resistant enterococci (ARE) have recently emerged as clinical pathogens in Sweden. Between 1991 and 1995 the incidence of ARE among enterococcal isolates at Uppsala University Hospital increased from 0.5% to 8.1%. Shedding of ARE from infected cases and risk factors for infection with ARE were studied during a period of 7 months for 38 ARE cases and 38 controls with ampicillin-susceptible enterococci. ARE cases had longer mean duration of hospitalization than controls (29 d vs. 15 d; p = 0.002). In univariate analysis other risk factors for infection with ARE were found to be prior therapy with > 2 antimicrobials (odds ratio [OR] 3.3; 95% confidence interval [CI] 1.2-9.5), > 4 weeks of antimicrobial therapy (OR 6.9; CI 1.8-28.3) and cephalosporin therapy (OR 9.1; CI 2.6-33.7). Fourteen of 26 skin carriers of ARE were found to be shedding ARE to the environment, compared to 2 of 12 non-skin carriers (p = 0.03). Pulsed-field gel electrophoresis suggested multifocal origin of the majority of the infecting ARE strains. Non-recognized fecal colonization and silent spread of ARE among many patients and over a prolonged time period is suggested to be the main explanation for the increase of ARE infections in our hospital. Infection control measures focusing on protecting patients at high risk for ARE infections and further efforts to optimize antimicrobial use are proposed.
PubMed ID
11303807 View in PubMed
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Analysis by pulsed-field gel electrophoresis of the genetic diversity among Clostridium perfringens isolates from chickens.

https://arctichealth.org/en/permalink/ahliterature56605
Source
Vet Microbiol. 2003 Jul 17;94(3):257-66
Publication Type
Article
Date
Jul-17-2003
Author
B. Nauerby
K. Pedersen
M. Madsen
Author Affiliation
Department of Poultry, Danish Veterinary Institute, Fish and Fur Animals, Hangøvej 2, DK-8200 Aarhus N, Denmark. bn@vetinst.dk
Source
Vet Microbiol. 2003 Jul 17;94(3):257-66
Date
Jul-17-2003
Language
English
Publication Type
Article
Keywords
Animals
Bacterial Typing Techniques - veterinary
Carrier State - veterinary
Chickens - microbiology
Clostridium perfringens - classification - genetics - isolation & purification
DNA, Bacterial - analysis
Denmark
Electrophoresis, Gel, Pulsed-Field - methods - veterinary
Enteritis - microbiology - veterinary
Enterotoxins - genetics
Phylogeny
Poultry Diseases - microbiology
Research Support, Non-U.S. Gov't
Variation (Genetics)
Abstract
The aim of this study was to analyse the genetic diversity among Clostridium perfringens isolates from Danish broiler chickens since both sick and presumably healthy animals were investigated. Isolates (n=279) collected from chickens from 25 farms were analysed by pulsed-field gel electrophoresis (PFGE) with the restriction enzyme SmaI. A high genetic diversity was found. Isolates with different PFGE types were toxin typed by PCR and all were found to be of type A. The results showed that healthy broiler chickens carried several different C. perfringens clones both within a flock and even within individual birds, whereas flocks suffering from necrotic enteritis (NE) or cholangio-hepatitis carried only one or two clones.
PubMed ID
12814893 View in PubMed
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Analysis of Neisseria gonorrhoeae in Ontario, Canada, with decreased susceptibility to quinolones by pulsed-field gel electrophoresis, auxotyping, serotyping and plasmid content.

https://arctichealth.org/en/permalink/ahliterature208613
Source
J Med Microbiol. 1997 May;46(5):383-90
Publication Type
Article
Date
May-1997
Author
N. Harnett
S. Brown
G. Riley
R. Terro
C. Krishnan
M. Pauzé
K H Yeung
Author Affiliation
Central Public Health Laboratory, Ontario Ministry of Health, Toronto, Canada.
Source
J Med Microbiol. 1997 May;46(5):383-90
Date
May-1997
Language
English
Publication Type
Article
Keywords
4-Quinolones
Anti-Infective Agents - pharmacology
Bacterial Typing Techniques
DNA, Bacterial - analysis
Electrophoresis, Gel, Pulsed-Field
Gonorrhea - epidemiology - microbiology
Humans
Incidence
Microbial Sensitivity Tests
Neisseria gonorrhoeae - classification - drug effects
Ontario - epidemiology
Plasmids
Restriction Mapping
Serotyping
Abstract
The incidence of Neisseria gonorrhoeae with reduced susceptibility to quinolones increased from 0.18% (63 of 3285) in 1992 to 0.56% (15 of 2663) in 1993 and 0.62% (46 of 2846) in 1994. In all, 65 of the 67 isolates of Neisseria gonorrhoeae with decreased susceptibility to quinolones were characterised by pulsed-field gel electrophoresis (PFGE), auxotyping, serotyping and plasmid content. The strains were distributed among 14 auxotype/serovar (A/S) classes. Thirty isolates (46.2%) which were penicillin-susceptible with ciprofloxacin MIC90 of 0.12 mg/L and norfloxacin MIC90 of 1.0 mg/L belonged to a single A/S class, OUHL/IA-2. All but two of the 30 isolates had identical PFGE restriction profiles with NheI restriction endonuclease. Fifteen isolates (23.1%) with MICs in the intermediate (or resistant) categories for penicillin and with ciprofloxacin and norfloxacin MIC90 of 0.25 and 4.0 mg/L and (0.5 and 4.0 mg/L) respectively, belonged to A/S class P/IB-1. The 15 isolates showed nine different patterns with NheI and eight patterns with SpeI restriction endonucleases. Two of three beta-lactamase-producing (PPNG) isolates belonged to A/S class P/IB-5 and had a dissimilar PFGE restriction profile with NheI endonuclease; the other isolate belonged to A/S class P/IB-8. The remaining 17 isolates were distributed among 11 A/S classes. Three isolates within the common A/S class NR/IB-1 were subdivided into two types by PFGE as were three isolates belonging to A/S class NR/IB-2. Overall the 65 isolates of N. gonorrhoeae were distributed into 30 NheI and 26 SpeI macrorestriction profiles. All but one isolate harboured the 2.6-MDa cryptic plasmid and 18 isolates carried the 24.5-MDa transferable plasmid. The three PPNG isolates carried the 4.5-MDa Asian beta-lactamase-producing plasmid and a 25.2-MDa conjugative plasmid was found in the two TRNG isolates.
PubMed ID
9152033 View in PubMed
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Analysis of Swedish Bordetella pertussis isolates with three typing methods: characterization of an epidemic lineage.

https://arctichealth.org/en/permalink/ahliterature149892
Source
J Microbiol Methods. 2009 Sep;78(3):297-301
Publication Type
Article
Date
Sep-2009
Author
A. Advani
H G J Van der Heide
H O Hallander
F R Mooi
Author Affiliation
Department of bacteriology, Swedish Institute for Infectious Disease Control (SMI), S-171 82 Solna, Sweden. reza.advani@smi.se
Source
J Microbiol Methods. 2009 Sep;78(3):297-301
Date
Sep-2009
Language
English
Publication Type
Article
Keywords
Alleles
Bacterial Typing Techniques - methods
Bordetella pertussis - classification - genetics - isolation & purification
Cluster analysis
DNA Fingerprinting - methods
DNA, Bacterial - chemistry - genetics
Electrophoresis, Gel, Pulsed-Field - methods
Humans
Minisatellite Repeats
Molecular Epidemiology - methods
Molecular Sequence Data
Polymerase Chain Reaction - methods
Sensitivity and specificity
Sequence Analysis, DNA - methods
Sweden - epidemiology
Whooping Cough - epidemiology - microbiology
Abstract
Three Bordetella pertussis typing methods, pulsed-field gel electrophoresis (PFGE), multi-locus sequence typing (MLST), and multi-locus variable number tandem repeat analysis (MLVA) were compared using a collection of Swedish strains. Of the three typing methods used, PFGE was found to be the most discriminatory. MLVA and MLST were less discriminatory, but may be valuable for strain discrimination when culture is not possible as they are based on PCR. The combination of MLVA/MLST was found to be equally discriminatory as PFGE and should therefore also be considered. The relationship between predominant lineages in Sweden and The Netherlands, characterized by the PFGE type BpSR11 and the allele for the pertussis toxin promoter ptxP3, respectively, was investigated. Linkage was found between the PFGE type BpSR11 and ptxP3 in that all BpSR11 strains carried ptxP3. On the other hand ptxP3 was found in several other PFGE-types. The presence of the ptxP3 allele in different genetic backgrounds may indicate horizontal gene transfer within B. pertussis or homoplasy. Alternatively, this observation may be due to convergence of PFGE types.
PubMed ID
19577594 View in PubMed
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An outbreak of CTX-M-15 -producing Escherichia coli, Enterobacter cloacae, and Klebsiella in a children's hospital in Finland.

https://arctichealth.org/en/permalink/ahliterature256922
Source
Scand J Infect Dis. 2014 Mar;46(3):225-30
Publication Type
Article
Date
Mar-2014
Author
Tanja Pasanen
Jari Jalava
Jenni Horsma
Eeva Salo
Mikko Pakarinen
Eveliina Tarkka
Martti Vaara
Päivi Tissari
Author Affiliation
From the Division of Clinical Microbiology, HUSLAB, Helsinki University Hospital , Helsinki.
Source
Scand J Infect Dis. 2014 Mar;46(3):225-30
Date
Mar-2014
Language
English
Publication Type
Article
Keywords
Child
Disease Outbreaks
Electrophoresis, Gel, Pulsed-Field
Enterobacteriaceae - drug effects - enzymology - genetics
Enterobacteriaceae Infections - epidemiology - microbiology
Finland - epidemiology
Hospitals, Pediatric - statistics & numerical data
Humans
beta-Lactamases - biosynthesis
Abstract
Four different extended-spectrum ß -lactamase (ESBL)-producing bacteria from a pediatric surgery ward were studied. The presence of TEM-, SHV-, and CTX-M-type ß -lactamases was analyzed and the relatedness of the isolates studied with a repetitive PCR system (DiversiLab) and pulsed-fi eld gel electrophoresis (PFGE). Molecular analysis showed that a clonal dissemination of CTX-M-15-producing Escherichia coli and Enterobacter cloacae had occurred.
PubMed ID
24303912 View in PubMed
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An outbreak of E. coli O157:H7 hemorrhagic colitis associated with unpasteurized gouda cheese.

https://arctichealth.org/en/permalink/ahliterature174645
Source
Can J Public Health. 2005 May-Jun;96(3):182-4
Publication Type
Article
Author
Lance Honish
Gerry Predy
Nyall Hislop
Linda Chui
Kinga Kowalewska-Grochowska
Larry Trottier
Cornelia Kreplin
Ingrid Zazulak
Author Affiliation
Capital Health-Public Health Division, Edmonton, Alberta. lhonish@cha.ab.ca
Source
Can J Public Health. 2005 May-Jun;96(3):182-4
Language
English
Publication Type
Article
Keywords
Alberta - epidemiology
Cheese - microbiology
Cluster analysis
Colitis - epidemiology - microbiology
Disease Outbreaks
Electrophoresis, Gel, Pulsed-Field
Escherichia coli - isolation & purification
Escherichia coli Infections - epidemiology - microbiology
Food Handling
Food Microbiology
Gastrointestinal Hemorrhage - epidemiology - microbiology
Humans
Abstract
A cluster of E. coli O157:H7 hemorrhagic colitis was identified in metro Edmonton, Alberta through notifiable disease surveillance in late 2002.
Environmental health officers collected food histories and clinical information from cases in the cluster. The provincial public health laboratory conducted pulsed field gel electrophoresis (PFGE) analysis on E. coli O157:H7 isolates from cluster cases. Public health and food regulatory agencies conducted an investigation when a food source (unpasteurized gouda cheese) was implicated.
PFGE analysis revealed an "outbreak" profile in 13 cases. Onset dates for the outbreak cases ranged between October 2002 and February 2003. Two cases, aged 22 months and 4 years, developed hemolytic uremic syndrome as a result of their infection. Consumption of unpasteurized gouda cheese produced at a local dairy farm was reported by 12 of 13 outbreak cases in the 2 to 8 days prior to illness. E. coli O157:H7 was isolated from 2 of 26 cheese samples manufactured by the implicated producer. The cheese isolates had indistinguishable PFGE profiles as compared with outbreak case isolates. Implicated cheese was found to be contaminated with E. coli O157:H7 104 days after production, despite having met regulated microbiological and aging requirements.
To our knowledge, this is the first confirmed outbreak of E. coli O157:H7 infection in Canada associated with raw milk hard cheese. A review of federal legislation vis-à-vis raw milk hard cheese may be in order.
PubMed ID
15913080 View in PubMed
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