An outbreak of gastroenteritis occurred in a village on the Island of Crete, with 1479 inhabitants. One hundred and thirty–eight symptomatic patients from 57 different families were examined. Thirty percent of children under 12 years were affected compared with 4% of adolescents and adults (P < 0.0001). Thirty–five out of 105 stool cultures (33%) grew Shigella sonnei. Thirty–four isolates had the same susceptibility pattern and were sensitive to ampicillin, while one was resistant to this antibiotic. Thirty–three isolates had the same plasmid profile. Based on epidemiologic and environmental findings, it was concluded that the transmission of shigellosis was waterborne. Shigella were not isolated from water, but one of the three village springs was found to be contaminated with faecal coliforms. This spring was probably contaminated by sewage material, due to its proximity to a source of untreated sewage effluent. Implementation of environmental and control measures brought the epidemic to an end.

To determine risk factors for cholera in an epidemic-disease area in South America, a case–control investigation was performed in Guayaquil, Ecuador, in July 1991. Residents > 5 years old who were hospitalized for treatment of acute, watery diarrhoea and two matched controls for each were interviewed regarding sources of water and food, and eating, drinking, and hygienic habits. Interviewers inspected homes of case-patients and controls to document water treatment, food-handling, and hygienic practices. Faecal specimens and shellfish were cultured for Vibrio cholerae O 1. Isolates were tested for susceptibility to a variety of antimicrobial agents. Drinking unboiled water (odds ratio [OR] = 4.0, confidence interval [CI] = 1.8–7.5), drinking a beverage from a street vendor (OR = 2.8, CI = 1.3–5.9), eating raw seafood (OR = 3.4, CI = 1.4–11.5), and eating cooked crab (OR = 5.1, CI = 1.4–19.2) were associated with illness. Always boiling drinking water at home (OR = 0.5, CI = 0.2–0.9) was protective against illness. The presence of soap in either the kitchen (OR = 0.3, CI = 0.2–0.8) or bathroom (OR = 0.4, CI = 0.2–0.9) at home was also protective. V. cholerae O 1 was recovered from a pooled sample of a bivalve mollusc and from 68% of stool samples from case-patients. Thirty-six percent of the isolates from stool specimens were resistant to multiple antimicrobial agents. Specific prevention measures may prevent transmission through these vehicles in the future. The appearance of antimicrobial resistance suggests the need for changes in current methods of prevention and treatment.

In May 1992. a small, circumscribed community outbreak of infection due to verotoxin-producing Escherichia coli O157 phage type 49 occurred in a semi-rural area of south-east Scotland. On the basis of stool cultures, six cases were identified, one of whom was asymptomatic. One child developed the haemolytic uraemic syndrome. Although the source of infection of the index case was not established nor could the extent of person-to-person spread be fully determined, the clinical, microbiological and epidemiological evidence available indicated that a children's paddling pool served as the focal point in the transmission of infection causing the outbreak.

Transfer of shigella R–plasmids in vivo has seldom been demonstrated. Strains of Shigella dysenteriae type 1 and Shigella flexneri type 5b were isolated from a Bulgarian traveller who visited Vietnam and developed dysentery, which was treated with trimethoprim/sulfamethoxazole (TMP/SMZ) for a short time. Both species of shigellae are unusual in Bulgaria where strains of S. sonnei predominate. Both shigella strains were multiresistant to the same antimicrobial agents. Each strain contained a 48–kilobase plasmid that conferred the entire resistance phenotype to a susceptible Escherichia coli. Restriction endonuclease patterns of plasmid DNA from the respective strains were identical. Transmissible plasmids of the same resistance phenotypes and restriction patterns were isolated from the patient's colonic E. coli. Transconjugants hybridized to a dihydrofolate reductase type I–DNA probe. These studies support the hypothesis that R–plasmid transfer may occur between non-pathogenic, faecal strains and pathogenic shigellae, a process that may have been facilitated by inadequate treatment with TMP/SMZ at the onset of the illness.

The distribution of the Escherichia coli attaching and effacing (eae) gene in strains of verotoxin-producing E. coli (VTEC) isolated from cattle and humans was studied. The majority of strains isolated from humans with bloody diarrhoea or HUS and cattle with severe diarrhoea were eae. positive (82 and 83% respectively). In contrast. 59% of VTEC isolated from asymptomatic cattle were eae negative and of the remaining 41 % that were eae positive, the majority were serotype O157.H7. The nucleotide sequence of the 3′ end of the eae gene of enteropathogenic E. coli (EPEC) of serotype O55.H7 was found to be almost identical to that of serotype O157. H7. Specific primers are described which detect the eae sequences of VTEC serotypes O157.H7, 0157.H−, and EPEC serotypes O55.H7 and O55.H−. The nucleotide sequence of the 3′ end of the eae gene of serotype O111.H8 differed significantly from that of O157.H7. Primers were developed to specifically identify the eae sequences of VTEC serotypes O111. H− and O111.H8. We conclude that whereas the majority of VTEC associated with disease in cattle and humans possess the eae gene, the gene itself may not be necessary to produce haemorrhagic colitis and HUS. Sequence heterogeneity in the 3′ end of eae alleles of VTEC permits specific identification of subsets of these organisms.

The effects of ingested Salmonella enteritidis (SE) dose on incubation period and on the severity and duration of illness were estimated in a cohort of 169 persons who developed gastroenteritis after eating hollandaise sauce made from grade–A shell eggs. The cohort was divided into three groups based on self–reported dose of sauce ingested. As dose increased, median incubation period decreased (37 h in the low exposure group 21 h in the medium exposure group v. 17·5 h. in the high exposure group, P = 0.006) and greater proportions reported body aches (71 v. 85 v. 94%, P = 0.0009) and vomiting (21 v. 56 v. 57%, P = 0.002). Among 118 case-persons who completed a follow–up questionnaire, increased dose was associated with increases in median weight loss in kilograms (3.2 v. 4.5 v. 5.0, P = 0.0001), maximum daily number of stools (12.5 v. 15.0 v. 20.0, P = 0.02), subjective rating of illness severity (P = 0.0007), and the number of days of confinement to bed (3.0 v. 6.5, P = 0.04). In this outbreak, ingested dose was an important determinant of the incubation period, symptoms and severity of acute salmonellosis.

When Pst I–generated digests of genomic DNA from each of the type strains of 49 of the Vi phage types of Salmonella typhi were probed with a PCR–amplified IS200 gene probe, all strains were found to possess at least 11 IS200 elements carried on fragments in the range 24.2–1.2 kb. Fourteen fingerprints were identified but two patterns designated IS200Sty1 and IS200Sty2 predominated. In one strain, a plasmid–mediated IS200 element was identified. When IS200 fingerprinting was applied to epidemiologically–unrelated strains of S. typhi isolated in Ecuador, 3 patterns were identified in 10 strains belonging to 9 different phage types. It is concluded that Vi phage typing remains the method of choice for the primary differentiation of S. typhi but that IS200 fingerprinting may be of limited use in laboratories which do not have access to phage typing.

Plasmids were found in 1022 of 1089 (94%) of drug–sensitive strains of Salmonella enteritidis phage type 4 from humans (sporadic and outbreak cases), poultry (chickens) and eggs in England and Wales in the 5-year period 1988–92 and 25 plasmid profile patterns were identified. Strains characterized by a single plasmid of 38 MDa predominated ( = plasmid profile type SE 38), comprising over 90% of isolates from humans, 70% from poultry and 92% from eggs. Eleven profile types were identified in strains from humans, 21 in strains from poultry and 3 in strains from eggs. Eight of the 11 patterns identified in human isolates were found in strains from poultry and 2 in strains from eggs. In contrast 15 patterns seen in poultry were not found in strains from humans. Four percent of strains from humans and 13% from poultry did not carry the 38 MDa plasmid but all strains from eggs were found to carry this plasmid. The second most common profile type in strains isolated between 1981 and 1988 was not identified in strains isolated from 1988–92. It is concluded that plasmid profile typing is a useful method for rapid differentiation within phage type 4 of S. enteritidis but that methods which can discriminate within the predominant profile type, SE 38, are now required.

We describe the disease spectrum and socio-demographic and epidemiological features of an epidemic of cholera due to a new pathogen. Vibrio cholerae O139, in patients attending a very large hospital in the metropolitan city of Dhaka, Bangladesh.

This hospital treats 70000–90000 patients a year with diarrhoeal diseases. A 4% systematic sample of 1854 patients attending from January to April 1993 were studied.

Five hundred and two (27%) of the 1854 patients were culture positive for V. cholerae O139 and 63 (3%) were culture positive for V. cholerae O1 biotype El Tor. Patients with V. cholerae O139 were mainly adults with a short history of watery diarrhoea. Eight-three percent of patients had moderate to severe dehydration. All recovered except one 80-year-old man with compromised renal function who died. Seventy-eight percent of patients required initial intravenous rehydration followed by oral rehydration therapy with rice ORS; they also received tetracycline to reduce diarrhoea severity. Most patients were from urban slums with inadequate sanitation facilities and hygiene practices.

The newly recognized V. cholerae O139 infection produced an epidemic of severe dehydrating diarrhoea indistinguishable from clinical cholera in a population which experiences two epidemic peaks of cholera in a year due to V. cholerae O1. Infection with the latter does not appear to confer any cross-protection from V. cholerae O139. The new pathogen suppressed, albeit temporarily, V. cholerae O1. Unlike other non-O1 serogroups of V. cholerae this new serogroup appears to have epidemic potential.

Restriction fragment length polymorphism of ribosomal RNA genes was analysed among 133 Escherichia coli strains predominantly from blood and urine, including 21 isolates from faeces of healthy persons. The strains had also been characterized for their O:K:H serotypes, for the presence of P, S and type 1C fimbriae, non–P, non-S mannose–resistant haemagglutinins and haemolysin production. Hind III–digested genomic DNA was subjected to Southern blot analysis with either plasmid pKK3535 containing E. coli rRNA operon or purified rRNA as a probe. Among the 133 strains 20 ribotypes were obtained. The distribution of strains into different ribotypes generally correlated with their O:K:H serotype. Ribotype variation within serotypes was mainly seen among strains with the K5 capsule. The origin of the strains or the presence of virulence-associated factors did not correlate with the ribotype. In conclusion, ribotyping appears to be a valuable method in epidemiologic studies especially when the serotyping methods are not available.

The important role of plasmid genes in assessing virulence for BALB/c mice in salmonella, and the difficulty of using standard techniques to detect them, led us to develop a detection method by gene amplification.

One hundred and forty–three strains (71 serovars) of salmonella and 35 strains of other species were tested using specific oligonucleotide primers. The amplification products were identified by a specific oligonucleotide probe. Forty-nine salmonella strains from ten serovars (S. abortus ovis, S. choleraesuis, S. dublin, S. enteritidis, S. gallinarum / pullorum, S. hessarek, S. typhimurium, S. IIIa 48:z4, z23, S. IV 43: z4, z23:-, S. V 28:a:-) produced a positive and specific response.

Because of various origins of the strains possessing the gene sought and the diversity of the responses, both from one serovar to another and in the same serovar, this search has its place among the epidemiological markers in general use. This method appears well suited to the research and detection of plasmid genes associated with mouse virulence in salmonella.

Escherichia coli serotype O147:K89:K88a,c was found to be associated with outbreaks of diarrhoea in preweaner pigs of up to 4 weeks of age on a pig unit. Resistance to apramycin, gentamicin, netilmicin, tobramycin and other antibiotics was associated with conjugative plasmids of approximately 62 kb. The presence of a gene which encoded for the aminoglycoside acetyltransferase enzyme AAC(3)IV was confirmed by DNA hybridization.

Samples collected during the following 12 months revealed widespread dissemination of these resistance plasmids in non-serotypable, non-haemolytic E. coli throughout the farm. Apramycin-resistant E. coli were also isolated from a stockman and it appeared from plasmid profile analysis and antibiotic sensitivity testing that the human isolates carried the same plasmid as that carried by the porcine E. coli. Klebsiella pneumoniae, with a slightly smaller conjugative plasmid and similar resistance pattern, was isolated from the stockman's wife.

The general bacterial flora of 38 Tasmanian SIDS infants was examined together with faecal flora of 134 comparison infants ranging in age from birth to 6 months. The microflora of all specimens received was investigated with special emphasis on the toxigenic Escherichia coli (TEC). Samples were examined for verocytotoxigenic E. coli, free faecal verocytotoxin (FVT), heat labile toxin (LT) and heat stable toxin (ST) producers with the use of a Vero cell assay and commercial kits. The findings of this study revealed a high isolation rate (39%) of TEC from SIDS infants as compared to 1.5% from the healthy comparison infants. Atypical E. coli strains were also identified during the study, including E. coli A–D. An analysis of the same specimens for rotaviral and adenoviral antigens indicated that 30% of the SIDS cases were positive as compared to 20% in the comparison group.

A total of 675 stdrains of Salmonella bareilly received from different parts of India and France during 1959–92 were phage typed using six bacteriophages. Overall ttypability achieved was 90·8% with 23 distinctphage types excluding a group of untypable strains. Phage types have been defined in octal code. Simpson's coefficient was applied for diversity index having a value of 0·839. This system was found to be reproducible, stable and epidemiologically useful.

The incidence of gastrointestinal diseases was studied in a community-based study in four regions of The Netherlands. Two grades of severity were distinguished − 1: diarrhoea or vomiting and at least 2 additional symptoms within the period of 1 week, and 2: diarrhoea or vomiting and at least 2 additional symptoms occurring on the same day lasting at least 2 days within the period of 1 week. The incidence of gastrointestinal episodes was calculated to be 630 for grade 1 and 180 for grade 2 disease per 1000 person-years, after correction for age and sex. The incidence was higher for women than for men (relative risk 1·25) and lower for those in the 19–64-year-old age group when compared to those younger or older (relative risk 0·75 and 0·40. respectively). Independent of the degree of severity of the symptoms, about 20% of the patients had consulted a general practitioner, about half in person and half by telephone. It is concluded that community studies are essential to assess the real incidence of gastrointestinal diseases in the population.

The seasonal variation in the occurrence of V. vulnificus in relation to water temperature and salinity was studied along the Dutch coast. In two consecutive years V. vulnificus strains could be isolated in August when the water temperature was highest. The indole-positive strains isolated from North Sea water samples were identical to most strains isolated from human disease and from the environment. However, strains isolated from four of five patients living in countries around the North Sea were different from the North Sea isolates in that they were indole-negative and have a lower NaCl tolerance.

The electrophoretic variations of carboxylesterase B and of esterases A, C and I, the presence of mannose resistant haemagglutinin, α–haemolysin, cytotoxic necrotizing factor type 1 (CNF1) and certain O antigens were compared in 150 strains of Escherichia coli responsible for extra-intestinal infections. Electrophoretic mobilities of outer membrane proteins (OMP) were also studied for strains belonging to O4, O6, O7, O8 and O75 serogroups. Fast migrating allozymes of carboxylesterase B (pattern B1) were correlated with slow migrating allozymes of esterase C, serogroups O7 and O8, lack of virulence factor, and particular OMP patterns, whereas slow migrating allozymes of carboxylesterase B (pattern B2) were correlated with fast migrating allozymes of esterase C, serogroups O2, O4, O6, O18 and O75, virulence factor production, and distinct OMP patterns. Allozymes of esterases A and I were not clearly correlated with the distribution of virulence factors. The pattern B2 was more strongly associated with CNF1 than with α–haemolysin and mannose resistant haemagglutinin. These results substantiate the view that the electrophoretic pattern B2 of carboxylesterase B identified most of the highly pathogenic strains implicated in extra-intestinal infection of humans.

Seven hundred and thirty-four isolates of Staphylococcus aureus, recovered from the sputum of 238 cystic fibrosis patients in six French hospitals, were characterized by esterase electrophoretic typing, capsular polysaccharide serotyping and phage typing and tested against 14 antibiotics for sensitivity. Thirty-four esterase electrophoretic types were found with a genotypic diversity coefficient of 0·91. Five hundred and forty-eight (78·7%) isolates produced capsular polysaccharide and 350 (50·3%) were type 8. Four hundred and sixty isolates (66·6%) were phage typable and 202 (28·2%) were lysed by group III bacteriophages. No esterase electrophoretic type, capsular type or phage type was specific to cystic fibrosis. Isolates belonged to a wide range of types, similar to strains acquired outside hospitals. Eighty-five patients had three or more consecutive isolates over at least 6 months. The ability of S. aureus to persist for long periods of time has been demonstrated in 73% of them. Methicillin-resistance was encountered among 73 strains (9·8%) which were also multiresistant. Two hundred and eighty-nine (39·9%) strains were sensitive to all antibiotics tested except to penicillin. Pristinamycin and co-trimoxazole were the most effective antibiotics. These results could contribute to the elaboration of a rational approach to the prophylaxis and therapy of respiratory staphylococcal infections in cystic fibrosis patients.

One hundred and eighty–one stool specimens from patients with various types of diarrhoea (135 patients) or from non-diarrhoeal controls (23 acute medical patients, 23 inflammatory bowel disease in remission) were investigated using a colony–blot DNA hybridization assay for the presence of Verocytotoxin–producing (VTEC), enteroaggregative (EAggEC) and diffusely adherent (DAEC) Escherichia coli. Twelve patients had probe–positive EAggEC in the stool and 8 of these had diarrhoea, 6 following recent travel. Eight patients had DAEC, 7 of whom had travellers diarrhoea. Six of 10 (60%) travellers with gastroenteritis, but without a recognized enteric pathogen, were positive for EAggEC (4) or DAEC (2). Five of 10 (50%) travellers with gastroenteritis related to a recognized enteric pathogen also had DAEC identified in their stool. Of the 23 acute medical control patients 11 had been abroad, 4 of these were immigrants and had EAggEC. VTEC were not found and, with one exception, immunoassays for antibodies to E. coli O 157 and O 2 lipopolysaccharides were negative.

Sixty-nine Staphylococcus aureus strains. 39 of which produced staphylococcal enterotoxin B (SEB + ) and 14 of which were associated with toxic shock (TS + ), were studied using the following markers: serotyping, phage typing, antibiotyping. ribotyping, zymotyping and pulsed-field electrophoresis typing. Analysis of the results showed that the enterotoxin B producing strains were derived from at least three clones: the first two consisted of methicillin-susceptible strains, while the third included the methicillin-resistant (MRSA) strains. TS+ strains of non-genital origin appeared to be distributed between the three clones, with no specific characters.