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Body lice transport B. recurrentis from man to man and humans are the only host. The presence of lice in Italy and an increasing number of cases in migrants can contribute to the onset of autochthonous cases. In this paper, we report a new case of Louse-borne Relapsing Fever (LBRF) diagnosed among migrants in Sicily exactly one year after the first case was recorded. We reviewed all cases reported in Europe from February 2016 until now. Our study identified two new cases of LBRF in migrants arrived in Europe: one who came from Somalia and one from Mali. Here we report data on a new case in Sicily. The number of migrants and refugees to transit in Sicily has increased, and this has led to the introduction of infectious diseases. Therefore, in our opinion it is essential to upgrade control of the sanitation conditions of migrants.

Escherichia coli ST131 is an emerging resistant agent recently called “superbug” in England. This strain is responsible of community-acquired urinary tract infections and nowadays showing increasing resistance to antibiotics like fluoroquinolones and cephalosporins. Survey of virulent bacterial clone is relevant to control its spreading in community. We aim to assess the circulation of resistant clones Escherichia coli ST131 outside of the hospital to prompt control of outbreak in our geographical area. We selected 105 E. coli resistant isolates from community-acquired urinary infections and performed a multiplex PCR to evaluate if they belonged to the ST131 type. We investigated their set of virulence factors; in particular, kpsMII, papA, sfaS, focG, iutA, papC, hlyD and afa genes, and finally, we evaluated beta lactamases genes and quinolone resistance determinants. E. coli ST 131 clone was present in 66.6% of our isolates and showed positivity to a wide range of resistance genes, in particular blaCTX-M-15 among beta lactamases and plasmid-related quinolone resistance genes (qnrA, qnrS and aac (6’)-Ib-cr). Moreover, 81% of the strains showed positivity to at least one of the virulence factor genes. Our results suggested a high presence of E. coli ST131 in community. We suggest antibiotic stewardship for outpatient clinicians and facilities to contain the spread of “superbug” agents.

A major virulence factor of Staphylococcus epidermidis is its ability to form biofilms, permitting it to adhere to a surface and, in turn, to form a mucoid layer on polymer surfaces. Multiple factors have been found to influence bacterial attachment. Currently, this bacterium is commonly associated with hospital infections as a consequence of its ability to colonize, albeit accidentally, medical devices. This study investigated the genetic and phenotypic formation of biofilm in 105 S. epidermidis strains isolated from the skin of hospitalized patients. Fifty-eight of these patients were positive for the mecA gene (MRSE) and 47 were found to be negative (MSSE). Genetic characterizations were performed for the detection of the mecA, icaADBC, atlE, aap, bhp, IS256 and agr groups by PCR. Biofilm production was examined by culturing the strains in TBS medium and TBS with 0.5 and 1% respectively of glucose, and a semiquantitative assay on tissue culture plates was used. Although a molecular analysis estimate of detailed biofilm formation is costly in terms of time and complexity, a semiquantitative assay can be proposed as a rapid and cheap diagnostic method for initial screening to discover virulent strains. We confirmed a close correlation between genetic and phenotypic characteristics, highlighting the fact that, when S. epidermidis isolates were cultured in TSB with 1% of glucose, an increase in biofilm production was observed, as confirmed by positivity for the ica locus by molecular analysis.

Recent reports indicate an increase in rates of infection and disease due to rapidly growing mycobacteria (RGM) in patients with pre-existing chronic lung disease. Studies have described difficulties in correctly identifying closely related species, even when proper methodologies are adopted, and several different gene targets have been proposed. We describe two cases of RGM infection in a 29-year-old HIV-1 positive Congolese man and a 19-year-old HIV-1 positive Liberian woman, respectively, both with bronchiectasis due to previous Mycobacterium tuberculosis (MTB) infection. Mycobacterium porcinum and Mycobacterium bolletii were identified in bronchoalveolar lavage fluid and sputum, respectively. After starting the patients on antiretroviral treatment and primary prophylaxis against non-tuberculous mycobacteria (NTM), and ensuring that they adhered to their prescribed regimen, we observed an improvement in their clinical condition and mycobacteria cleared from their respiratory specimens. Management of RGM respiratory infection in immunocompromised patients has to be evaluated on a case-by-case basis, taking into account the patient's pulmonary sequelae, adherence to multiple treatments and immune profile.

During a three-year period, from April 2002 to May 2005, one hundred-forty-seven samples, taken from technical systems of water distribution at point of use, were repeatedly collected at six different sites in Northern Sicily and assayed for the presence of Legionella pneumophila serogroup 1 and serogroups 2 to 14. At the first samplings, the water distribution systems of all the sites were heavily contaminated, and disinfection treatments by the superheat and flush method were therefore performed. Treatments were always successful against L. pneumophila sg.1, but only in a few cases against all other serogroups. Eighty-six strains of L. pneumophila sg. 1, isolated from 26 of these samples, were characterized by amplified fragment length polymorphism (AFLP) analysis and sequence-based typing (SBT) procedure. Perfectly overlapping results were obtained by both the procedures and four genotypes were identified, accounting for all the isolates. The easy transferability of the SBT data through a web-based database made it possible to identify the presence in Northern Sicily of the two SBT types most commonly circulating in Europe.

The incidence of gastrointestinal diseases and in particular gastric cancer (GC) is high worldwide. Over the last few years, numerous studies have speculated that Helicobacter pylori (H. pylori) and Epstein-Barr virus (EBV) can be correlated with gastric cancerogenesis. Virulence factors of H. pylori can contribute to the variability of clinical outcomes: among the most important virulence factors is the pathogenicity island (CagPAI), vacA and oipA gene. EBV infection usually persists in B cells and induces an inflammatory reaction in cooperation with H. pylori. In Sicily, H. pylori and EBV infections are particularly prevalent, and to our knowledge no study has addressed this yet. The aim of our study was to examine the association of H. pylori and EBV infection in patients with gastric diseases in Sicily. Gastric biopsies were collected from 24 adult patients with chronic gastritis active (CGA) and from 24 adult patients without any gastric disease (NGD) who underwent upper gastrointestinal endoscopy. H. pylori infection was diagnosed by PCR for ureaseA gene while EBV-DNA was detected by Real time PCR for region Bam HI-W. Moreoever, we investigated the presence of CagPaI and the status of vacA and oipA genes. Percentage of resistance to Clarithromycin of H. pylori was evaluated also. We established that H. pylori and EBV infection was present in 42% of patients, while dual infection with H. pylori and EBV-DNA was present in 54% of the patients with CGA. In patients with NGD we found that H. pylori and EBV infection was present in 46% and in 21% of patients respectively, while co-infection was present in 33% of patients. CagPAI was present in only 20% of patients with GCA and in 9% of patients with NGD. As regards vacA alleles, s2i2m2 were predominant, present in 80% and 82% of patients with CGA and NGD respectively. The status “ON” of oipA gene was present in the same percentage. Finally, we found that 38% of patients positive for H. pylori infection showed resistance to Clarithromycin. In our study, there was a strong association between the simultaneous presence of H. pylori and EBV infection in patients with CGA compared to patients with NGD. Furthermore, our data confirmed the high percentage of resistance among H. pylori strains circulating in Sicily, underlining the importance of establishing a therapy that is effective in eradicating them and reducing the frequency of coinfections and evolution towards gastric cancerogenesis

In this work, with the aim to obtain a wound dressing hydrogel, an amine derivative of gellan gum was crosslinked in the presence of 4arm-polyethylenglycole-vinylsulfone. Through this easy and reproducible chemical procedure, a hydrogel with advanced elastic properties and hydrolytic resistance under physiological conditions was obtained. The incorporation of different quantities of polydopamine in the gelling solutions allows to obtain different hydrogels with marked photothermal properties when irradiated with a laser in the near infrared at 810 nm. The organic nanoparticles, reacting with the amino groups of the polysaccharide derivative, contribute to increase the storage moduli of the hydrogels. Ciprofloxacin was loaded into the hydrogel with higher amount of polydopamine and drug delivery experiments were performed to investigate the effect of irradiation on the antibiotic release profile. Antimicrobial studies, evaluated against S. aureus and P. aeruginosa, revealed that generated hyperthermia exerts a direct inhibition on the pathogens growth and, in the case of S. aureus, adjuvates the ciprofloxacin antimicrobial effect.

Multidrug resistance among bacterial pathogens is an ongoing global problem and renders antimicrobial agents ineffective at treating bacterial infections. In the health care setting, infections caused by multidrug-resistant (MDR) Gram-negative bacteria can cause increased mortality, longer hospital stays, and higher treatments costs. The aim of the Tigecycline Evaluation and Surveillance Trial (TEST) is to assess the in vitro antimicrobial activities of tigecycline and other contemporary agents against clinically relevant pathogens. This paper presents antimicrobial activity data from the TEST study between 2004 and 2014 and examines global rates of MDR Gram-negative isolates, including Acinetobacter baumannii, Pseudomonas aeruginosa, and members of the Enterobacteriaceae, during this time. Our results show that tigecycline retained in vitro activity against many MDR Gram-negative pathogens over the study period, while rates of MDR A. baumannii increased globally. Using these findings, we hope to highlight the current status of multidrug resistance in medical facilities worldwide., Multidrug-resistant (MDR) Gram-negative organisms are a burden on the global health care system. The Tigecycline Evaluation and Surveillance Trial (TEST) is an ongoing global study designed to monitor the in vitro activities of tigecycline and a panel of marketed antimicrobials against a range of clinically significant pathogens. In this study, in vitro data are presented for MDR Acinetobacter baumannii, Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, Klebsiella oxytoca, Enterobacter aerogenes, and Enterobacter cloacae isolates collected from 2004 to 2014. In total, 13% (21,967/170,759) of isolates displayed multidrug resistance globally, with the highest rates recorded among A. baumannii (overall rate, 44% [8,294/18,741], increasing from 23% [309/1,323] in 2004 to 63% [447/712] in 2014). Other multidrug resistance rates ranged from 2.5% for K. oxytoca (203/8,000) to 12% for P. aeruginosa and K. pneumoniae (3,951/32,786 and 3,895/32,888, respectively), and rates among these pathogens remained stable during the study period. Against MDR E. coli, Klebsiella spp., and E. aerogenes, the lowest rates of resistance were to tigecycline (0.2%, 6%, and 12%, respectively), and the lowest MIC90 value against A. baumannii was observed for tigecycline (2 mg/liter; MIC range, ≤0.008 to ≥32 mg/liter). The only significant change in resistance to tigecycline during the study period was for MDR E. coli (P < 0.01), among which eight resistant isolates were identified globally from 2009 to 2013. In summary, these results show that tigecycline retained in vitro activity against the majority of MDR Gram-negative organisms presented here, but the rising rates of MDR A. baumannii highlight the need for the continued monitoring of global multidrug resistance. IMPORTANCE Multidrug resistance among bacterial pathogens is an ongoing global problem and renders antimicrobial agents ineffective at treating bacterial infections. In the health care setting, infections caused by multidrug-resistant (MDR) Gram-negative bacteria can cause increased mortality, longer hospital stays, and higher treatments costs. The aim of the Tigecycline Evaluation and Surveillance Trial (TEST) is to assess the in vitro antimicrobial activities of tigecycline and other contemporary agents against clinically relevant pathogens. This paper presents antimicrobial activity data from the TEST study between 2004 and 2014 and examines global rates of MDR Gram-negative isolates, including Acinetobacter baumannii, Pseudomonas aeruginosa, and members of the Enterobacteriaceae, during this time. Our results show that tigecycline retained in vitro activity against many MDR Gram-negative pathogens over the study period, while rates of MDR A. baumannii increased globally. Using these findings, we hope to highlight the current status of multidrug resistance in medical facilities worldwide.

In August 2015, Dipodascus capitatus was isolated from two patients admitted to the neonatal intensive care unit. Nosocomial acquisition of the fungus was suspected and epidemiological studies were undertaken. The patients were simultaneously hospitalized, and the comparison of the two isolates by two independent molecular typing methods have confirmed clonal dissemination of a single strain of D. capitatus. Antimicrobial susceptibility testing was useful for identifying the appropriated antifungal therapy in micafungin. To our knowledge these are the first described cases of neonatal D. capitatus infection and also the first report of successful treatment by micafungin.

L’incidenza delle infezioni micotiche ha subito negli ultimi decenni un incremento rilevante, sia in ambito ospedaliero che comunitario. In ambiente ospedaliero il problema sta assumendo dimensioni preoccupanti poiché, sebbene Candida spp. si debba considerare il principale responsabile di infezioni correlate ai miceti, emergono altre specie il cui ruolo deve essere accertato. In particolare Dipodascus capitatus, forma teleomorfica di Geotrichum capitatum, microrganismo che può risiedere nel suolo, sulla pelle e nel tratto respiratorio e gastroenterico, nel passato considerato un contaminate o un innocuo colonizzatore, da qualche anno è stato associato ad infezioni soprattutto nei pazienti immunocompromessi. Sebbene le infezioni da tale microrganismo siano spesso favorite dall’uso di antibiotici e di cateteri, le forme invasive sembrano verificarsi in pazienti neutropenici e nei soggetti sottoposti a chemioterapia intensiva per leucemia acuta. Dai reparti ad alto rischio sono stati anche rilevati episodi epidemici D. capitatus-correlati. Il suo riscontro non deve quindi essere sottovalutato ed è necessario poter disporre di test semplici che ne permettano una rapida identificazione. Tra i metodi fenotipici quello che si basa sulla valutazione della crescita in terreno cromogeno è considerato ottimale, soprattutto se si utilizza il CCA (Chromogenic Candida Agar, Oxoid); ed è stato già descritto quale metodo molecolare il sequenziamento. Anche dai reparti dell’A.O.U.P. “P. Giaccone” di Palermo, nel corso dell’ultimo anno, sono stati isolati stipiti di D. capitatus. I ceppi, provenienti da tre pazienti, da campioni diversi e da differenti reparti, sono stati identificati fenotipicamente, utilizzando il CHROMagar Candida (BD), e la loro identificazione è stata confermata tramite sequenziamento. Inoltre, al fine di valutare l’eventuale diffusione epidemica di questi isolati, sono stati utilizzati la PCR fingerprinting che prevede l’utilizzo della sequenza core del fago M13 e la RAPD (Random Amplification of Polymorphic DNA) utilizzando il primer Ope-4 e la combinazione dei primer W80A-Ap12h.

Background: Neisseria elongata subspecies nitroreducens is considered to be an important pathogen responsible for infective endocarditis, even if it is infrequently reported. We report the first case of endocarditis in Italy due to N. elongata subsp. nitroreducens. Case presentation: The infection occurs in a 40-year-old male affected by Marfan syndrome with a prosthetic aortic valve. The patient had had a fever for a week which had been resistant to antibiotic therapy. Conclusion: we propose a correct and rapid identification of Neisseria elongata subspecies nitroreducens by mass spectrometry directly from the positive blood culture. The rapidly identification obtained by MALDI-TOF it has enabled us to administer a correct empirical therapy.

The resistance of Helicobacter pylori strains to clarithromycin is increasing in several developed countries and their association with a genetic pattern circulation has been variously explained as related to different geographical areas. In this study we have reported: the prevalence of the resistance of H. pylori, isolated in Sicily, to clarithromycin; the principal point of mutation associated with this resistance; and the more frequent association between resistance to clarithromycin and cagA, the EPIYA motif, and the vacA and oipA genes. Resistance to clarithromycin was detected in 25 % of cases, the main genetic mutation involved being A2143G. The cagA gene was present in 48 % of cases and the distribution of the EPIYA motif was: ABC in 35 cases; ABCC in 8 cases; ABCCC in 2 cases; ABC-ABCC in 2 cases; and ABC-ABCC-ABCCC in 1 case. Regarding the vacA allele, an s1i1m1 combination was detected in 35 % of cases, s1i1m2 in 12 %, s1i2m2 in 12 %, s2i2m2 in 40 %, and a double s1m1-m2 mosaic in 1 % of cases. The status of the oipA gene was ‘off’ in 45 % of cases and ‘on’ in 55 %. Resistance to clarithromycin was found to be high in Sicily, but no correlation was found among resistance to clarithromycin, the vacA gene and oipA status; a higher correlation was observed between resistant strains and cagA-negative strains.

Introduction: Infection with Helicobacter pylori (H. pylori) evokes inflammatory and immune responses of the host, which most likely determine the clinical outcome of H. pylori infection. In the gastric epithelium, expression of human alpha-defensins, beta-defensins (hBD)-1, -2 and -3 has been detected in vivo. In particularly hBD3 as well hBD2 is known to be induced in gastric epithelial cells infection by the H. pylori and may be involved in the pathogenesis of H pylori-associated gastritis, possibly through its function as immune and inflammatory mediator. However, during prolonged infection, hBD3 was subsequently downregulated by the H. pylori virulence determinant CagA. Materials and Methods: Patients. In this study, serum and biopsies of 33 healthy individuals stratified according to the H. pylori infection (17 positive and 11 negative) was analyzed. Elisa Assay and Real Time PCR. Sera of patients were assayed by enzyme-linked immunosorbent (ELISA) assay for detection of both hBD- 2 (Phoenix Pharmaceuticals, Inc.) and hBD-3 (Alpha Diagnostic International) levels, according to the manufacture’s protocol. Protein concentration was expressed as pg/ml of serum volume. Real time PCR was carried out with the LC Fast Start DNA Master SYBR Green kit (LightCycler 2.0 Instrument, Roche; Milano, Italy) and PCR products were examined on 1.4% agarose gel. 192 Posters P 136 IMPACT OF HBV GENOTYPES A AND D GENETIC VARIABILITY ON INFECTION EVOLUTION Noemi Urone, Donatella Ferraro Sezione di Microbiologia “A. Chiarini”, Dipartimento di Scienze per la Promozione della Salute e Materno Infantile “G. D’Alessandro”, Università degli Studi di Palermo - Italy Introduction: HBV is characterized by a high genetic variability and several studies have demonstrated the correlation between viral variants and severe forms of acute and chronic liver disease. Few data are available about the impact of genetic variability on the evolution of acute infection. Recently, 5 SNPs (C504, C801, G1171, T1785 and A1786) into HBV genome were reported as potential novel markers linked to a lower rate of chronicity. The aim of this study was to analyze the genetic variability of HBV genotypes A and D isolates from cases of self-limiting acute (AHB) and chronic hepatitis (CHB) in order to identify HBV variants associated with chronicity or resolution of infection. Patients and Methods: The preS-S, preC-C and the overlapped P and X genes, were sequenced from sera of 33 AHB and 46 CHB Sicilian patients and analyzed with 92 HBV-A and D sequences from Gene Bank in order to identify HBV geno/subtype by phylogenetic analysis and to study the genetic variability. Results: Eighteen strains of HBV-D and 15 of HBV-A from AHB, 42 of HBV-D and 4 of HBVA2 from CHB patients were obtained. Two in frame deletions, between preS1 and preS2 regions (Δ173-321, Δ1-29) and in the S gene (Δ489-516) were detected in an AHB-D3 strain while 2 CHB-D1 strains showed the deletions Δ37-52 and Δ36-57 into preS2 region. The mutation M01I at preS2 start codon was detected in 2 AHB-D1 and a CHB-D1strains. Mutations of immune-escape were not found but >30% of strains showed many amino acid polymorphisms in “a determinant” domain. Secondary drug resistance mutations on RT-domains were identifiedGenotyping of H.pylori. The DNA of each biopsy, estracted using a High Pure Template Preparation Kit (Roche), was used to amplify following genes: ureA, cagA. Results: Protein levels of both studied defensins, hBD-2 and hBD-3, are lower or unchanged in serum of H. pylori- positive compared to those H. pylori- negative subjects. However, mRNA levels of hBD-2 and hBD-3 are up-regulated in most gastric biopsies of H. pylori-positive subjects, except in patients belonging to the genotype cagA+ vacA s1m1 EPIYA ABC. Conclusion: Although it has been demonstrated that H.pylori infection was associated with significant upregulation of hBD-2 and hBD-3 transcript levels in gastric mucosa, our data suggest that no similar association was found on protein level in serum of patients. In addition to, the upregulation of hBD-2 and hBD-3 transcript levels is absent in gastric biopsies of some H. pylori- positive subjects. These results suggest that, most likely, H. pylori strains belonging to a particular genotype not only inhibit pathogen-derived hBD-2 and hBD- 3 induction, but also block their constitutive expression to escape from the strong antimicrobial effects.

To the Editor,Human infections caused by methicillin-resistant Staphylococcus aureus (MRSA) sequence type 398 (ST398) have been emerging in recent y in Europe [1–3]. Most studies have shown a stron...

Cephalosporin-resistant Escherichia coli has been increasingly reported worldwide. In this study, 32 cephalosporin resistant E. coli isolates identified from cancer patients in Cairo, Egypt in 2009-2010 were analyzed. Twenty-three were of phylogenetic group D, seven A and one each B1 and B2. By rep-PCR 15 phylogroup D isolates were grouped in four clusters, one with sequence type (ST) 405 and three ST68. Seventeen isolates showed single patterns. blaCTX-M-15 and aac(6')-Ib-cr were the most common resistance determinants. blaOXA-48 and blaVIM were also detected. Multidrug resistant E. coli seriously affects healthcare, especially in immunocompromised hosts, such as cancer patients.

Background Multidrug-resistant Acinetobacter baumannii, initially considered as having a poor clinical relevance, is frequently isolated from infection cases in intensive care units. We describe the epidemiology of carbapenem resistant A. baumannii (CRAB) in a general ICU in Palermo, Italy, from October 2010 to March 2011. Findings 58 of 61 isolates exhibited MICs for meropenem or imipenem ≥16 mg/L. Forty-nine carried blaOXA-23 and two blaOXA-58 genes. Five subtype clusters were detected by rep-PCR. Clusters D and E included 10 isolates that tested negative for the carbapenem resistance genes. MLST attributed all isolates, but two, with sequence type (ST)2, whereas the two remaining isolates with ST78. The respiratory tract was the most common site of infection (26 out of 36 cases. 72.2%). A high infection related mortality rate was observed (18 out of 35 patients, 51.4%). Nineteen patients tested positive for other multidrug resistant organisms in addition to CRAB. In eight cases isolates belonging to distinct subtype clusters and/or with distinct carbapenemase profiles were identified. Conclusions Carbapenem resistance was prominently driven by the dissemination of CRAB isolates belonging to ST2, carrying the carbapenemase gene blaOXA-23. The colonization/infection of some patients by multiple strains is suggestive of an endemic circulation of CRAB.

Gram-negative pathogens producing carbapenemases represent an alarming clinical threat with serious effects on patient outcomes ([3][1], [7][2]). In 2001, Yigit et al. ([11][3]) reported a novel β-lactamase termed “ K lebsiella pneumoniae carbapenemase” (KPC-1) in North Carolina. KPC-producing

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is an emerging cause of infections outside of health care settings. We carried out a survey to determine the prevalence and characteristics of MRSA isolates (CA-MRSA, HA-MRSA) identified among in- and outpatients by the clinical microbiology laboratories of four general hospitals in Palermo, Italy during the period February-January 2010. Methods: Participating laboratories performed isolation, confirmed methicillin-resistance by their routine method and weekly sent their strains to the coordinating laboratory at the Department of Sciences for Health Promotion “G. D’Alessandro”, University of Palermo, Italy. The isolates were test for antimicrobial susceptibility by E-test and using the disk diffusion test. Presence of the mecA gene was investigated by PCR using primers and standard conditions. Multiplex PCR was performed to determine SCCmec types I to V.9 Strains assigned to SCCmec type IVa were submitted to polymerase chain reaction (PCR) for detection of the Panton-Valentine leukocidin toxin genes lukS-PV and lukF-PV. Multiple-locus variable-number tandem-repeat analysis (MLVA) was performed. Pulsed field gel electrophoresis (PFGE) was performed as previous reported. Multilocus sequence typing (MLST) was performed on the MRSA strains following the recommended procedure at the S. aureus MLST. Results: we collected 227 isolates from 185 patients. The distribution of MRSA from different wards was: intensive-care 25%, surgery 20%, internal medicine 33%, other 15,5% unknown 6,5%. 69% of MRSA strains were resistant to ciproflox and/or levofloxacin, 40% to macrolide and 38% to gentamycin. SCCmec type IVa has been found in 42 isolates from hospitalized patients. PFGE analysis showed 81 MLVA different banding patterns. Strains of MRSA ST398 were found. Conclusions: Detect circulation of MRSA clinically relevant strains through surveillance, timely hygienic interventions and cooperation by health care personnel are crucial to minimize or control health care-associated infections. The changing epidemiology of MRSA indicates that collaborative surveillance plans integrating human and animal information should be increased.

CagA is a major virulence factor of Helicobacter pylori that, once injected into the epithelial cells and phosphorylated on specific bacterial tyrosine residues within repeating EPIYA-A,-B,-C, and -D motifs, localizes to the plasma membrane and interacts with a number of intracellular effectors suggested to play an important role in Helicobacter pylori pathogenesis. EPIYA-D (in East Asian CagA) and EPIYA-C motifs (in Western CagA) are the main sites of CagA phosphorylation and the presence both of EPIYA-D or an increasing number of EPIYA-C motifs, rather than the general CagA positivity, has been associated with more severe gastroduodenal disease. With the aim to analyze EPIYA motifs in 24 cagA+ H.pylori isolates and in a number of recently collected, frozen, or, in particular, deparaffinized biopsies and clinical sample, all obtained from 62 patients with different H.pylori pathology, we comparatively evaluated EPIYA profiles by polymerase chain reaction amplification using single sets of primers flanking the variable EPIYA coding region, or a single forward primer and multiple reverse primers specific for the individual EPIYA motifs. Only the primers originally employed by Rudi et al. (1988)to amplify the variable 3'' region of the cagA gene allowed identification of EPIYA motifs in all biopsies and clinical samples. Multiple infections and EPIYA profiles with more than one EPIYA-C motif, in some cases confirmed by DNA sequencing, were observed in 12 and 22 patients, respectively. As expected, the increasing numbers of EPIYA-C motifs were associated with more severe gastric pathologies.

In a bacterium like Helicobacter pylori, which is characterized by a recombinant population structure, the associated presence of genes encoding virulence factors might be considered an expression of a selective advantage conferred to strains with certain genotypes and, therefore, a potentially useful tool for predicting the clinical outcome of infections. However, differences in the geographical and ethnic prevalence of the H. pylori virulence-associated genotypes can affect their clinical predictive value and need to be considered in advance. In this study we carried out such an evaluation in a group of patients living in Sicily, the largest and most populous island in the Mediterranean Sea. cagA, vacA, babA2, hopQ, oipA, sabA, and hopZ were the H. pylori virulence-associated genes assayed; their presence, expression status or allelic homologs were detected in H. pylori DNA samples and/or isolated strains, obtained by gastric biopsy from 90 Sicilian patients with chronic gastritis, inactive (n = 37), active (n = 26), or active with peptic ulcer (n = 27). Genotypes cagA (+), vacAs1, vacAm1, babA2 (+), and hopQ I, I/II were identified in 51.8, 80.4, 35.2, 47.3, and 67.7% of the different samples respectively. Only these genotypes were associated with each other and with the active form of chronic gastritis, irrespective of the presence of a peptic ulcer. In our isolates their prevalence was more similar to values observed in the north of Italy and France than to those observed in Spain or other Mediterranean countries that are closer and climatically more similar to western Sicily.

The association of Helicobacter pylori (Hp) infection with gastric cancer is well known and might be considered a paradigmatic example of the role that interaction among environmental factors and individual background might play in inducing age-associated disease. To evaluate the role of interaction of Hp infection with genetic background, gastric cancer and chronic gastritis patients as well as random selected controls were typed for five inflammation-related polymorphisms of IL-1 and IL-10 cytokine genes. No association among IL-10 or IL-1 variants with an increased risk of gastric cancer was found, whereas an Hp-independent association of IL-1beta -511T positive genotypes to an increased risk of chronic gastritis was found (Hp-/511T+ OR 1.89, 95% CI: 1.01-3.54; Hp+/-511T+ OR 1.83, 95% CI: 1.05-3.19). Stratification of gastric cancer group according to Hp infection does not allow finding a statistically significant association of Hp+ to the higher histological grading (G3) of gastric cancer (OR 1.54, 95% CI: 0.46-5.11). Our findings seem to confirm that cytokine genetic variants might contribute to determining the background for inflammaging in which H. pylori infection might facilitate cancer development.

To the Editor: Methicillin-resistant Staphylococcus aureus (MRSA) sequence type (ST)398 has become increasingly common in livestock, particularly pigs, in some countries in Europe, such as Spain and Germany (1). In Italy, prevalences as high as 14% and 21.6% in pig-breeding facilities and meat-processing sites, respectively, have been recently reported (1). Possible association of MRSA in animals with infection in humans has been investigated. One study showed a strong relationship between contact with pigs or calves and carriage by persons having direct contact with animals and families of persons who handle animals (2). Moreover, an MRSA prevalence >11.9% has been described by de Boer et al. (3) in meat, with 85% of isolates belonging to the ST398 lineage. MRSA ST398 has been described as a lineage with limited virulence and ability to spread between humans, but severe clinical manifestations, such as wound infections and endocarditis, have been recently attributed to this clone (1,4). Cases of nosocomial ventilator-associated pneumonia have also been reported in Germany (1). Moreover, an outbreak of infection with MRSA ST398 occurred in a surgical ward of a hospital in the Netherlands in 2007 (5). MRSA ST398 is an infrequent cause of human infections in Italy. No isolates belonged to this lineage in 2 studies of MRSA in Italy during 2006–2007 (6) or in hospitals during 1990–2007 (7). Only 1 invasive infection has been recently reported in a pig farm worker (8). We report a case of ventilator-associated pneumonia caused by MRSA ST398 in a patient in Palermo, Italy. The patient and his household members did not report any exposure to companion or livestock animals. The case-patient was a 78-year-old man admitted to a cardiac intensive care unit (ICU) of ARNAS Ospedale Civico Di Cristina e Benfratelli in Palermo on January 31, 2009, because of a recent history of unstable angina pectoris and acute anemia caused by duodenal ulcers. After cardiocirculatory arrest, he was transferred to a general ICU on February 3. The patient had type 2 diabetes and ischemic-hypertensive cardiomyopathy. MRSA nasal colonization at admission was not investigated because the patient lacked risk factors for screening at admission, e.g., antimicrobial drug therapy, hospitalization for >48 hours or time in a long-term care facility within the past 6 months, need for long-term nursing care, presence of indwelling devices, or chronic skin lesions. The clinical course of the patient’s illness was characterized by serious hemodynamic instability and difficulty in weaning from mechanical ventilation. Two bronchial aspirate specimens were cultured on February 4 and 9, when he was being treated with a third-generation cephalosporin (ceftriaxone). These cultures showed Staphylococcus epidermidis and S. saprophyticus. On the 14th day in the ICU, clinical signs of ventilator-associated pneumonia developed in the patient. He had increased sputum production, fever (38.8°C), leukocytosis, and infiltrates were seen on a chest radiograph. Empiric antimicrobial drug therapy with glycopeptides and a β-lactam/β-lactamase inhibitor combination was started. Culture of bronchial secretions yielded MRSA that was susceptible to glycopeptides, rifampin, linezolid, macrolides, and sulfamethoxazole and resistant to fluoroquinolones and tetracyclines. Three days later, linezolid was given, but the patient died after an acute myocardial infarction. The isolate was identified genetically by mecA PCR. It was not typeable by pulsed-field gel electrophoresis after digestion with SmaI, negative for Panton-Valentine leukocidin, and carried staphylococcal cassette chromosome mec (SCCmec) type IVa (9). Multilocus sequence typing, performed according to a recommended procedure (http://saureus.mlst.net/misc/info.asp), identified the isolate as ST398. A 1-year epidemiologic survey on MRSA isolates from 4 general hospitals in Palermo, which had begun on February 2009, did not identify any MRSA isolate carrying SCCmec type IV or V in patients admitted to the ICU until September 2009. However, colonization or infection by MRSA ST398 in the ICU patients before the study period could not be ruled out. Although an MRSA screening policy for the ICU staff members was not being carried out, a nosocomial chain of transmission appeared to be unlikely. Our results indicate that a new zoonotic clone of MRSA is emerging as a potential cause of serious human infections. Screening at hospital admission would likely help efforts to determine whether exposure to pet animals and livestock had occurred. However, the absence of specific exposure to zoonotic clonal lineages, as in our case-patient, is a matter of concern in terms of screening and contact tracing policy for MRSA infections. Prevalence of MRSA and distribution of MRSA sequence types in livestock in Italy are not known. However, surveys of foods of animal (pig) origin have showed an MRSA prevalence of 3.7% (1,10). In view of the low prevalence of MRSA ST398 in patients with no exposure to animals, food products currently seem to play a negligible role. However, this clone is likely spreading because of the large animal reservoir of ST398 and the global market for meat and livestock. The changing epidemiology of MRSA indicates that collaborative surveillance plans integrating human and animal information should be increased.

Summary: Epidemic spread of methicillin-resistant Staphylococcus aureus (MRSA) strains carrying the Staphylococcal Chromosomal Cassettes (SCC) mec type IV is being increasingly reported in many geographical areas. A survey to determine the prevalence and characteristics of MRSA SCCmec IV isolates identified in four general hospitals in Palermo, Italy, was carried out. During the period February–June 2009, SCCmec type IVa has been found in 12 out of 94 isolates. Nine isolates from all hospitals and all strains from a NICU outbreak occurring in the same period were attributed with the ST22-IVa (EMRSA-15) clone. In our setting, due to the changing MRSA epidemiology, detection of SCCmec IV could be poorly predictive of CA-MRSA. Keywords: MRSA, ST22-IVA, EMRSA-15, Epidemiology, Molecular typing