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CMI Research Notes 1007

determinants in regard to Enterobacteriaceae remains to be 14. Rhodes G, Parkhill J, Bird C et al. Complete nucleotide sequence of determined. For Aeromonas spp. to act as a reservoir of qnr conjugative tetracycline resistance plasmid pFBAOT6, a member of a group of INcU plasmids with global ubiquity. Appl Environ Microbiol genes, they must be capable of acquiring these determinants 2004; 70: 7497–7510. from their progenitors [13] and of transferring this genetic information to Enterobacteriaceae. Because Aeromonas are Detection and susceptibility testing of amphoriforme ubiquitous in a wide range of environments, they might act isolates from as important vectors for the transfer of plasmid-mediated patients with respiratory tract infections quinolone resistance [14].

S. Pereyre1, H. Renaudin1, A. Touati2, A. Charron1, Transparency Declaration O. Peuchant1, A. Bon Hassen2,C.Be´be´ar1 and C. M. Be´be´ar1 1) Laboratoire de Bacte´riologie EA 3671, Mycoplasma and Chlamydia Infections in Humans, Universite´ Victor Segalen Bordeaux 2 and CHU de The authors declare that they have no conflicts of interest in Bordeaux, Bordeaux, France and 2) Service des Laboratoires, Centre relation to this work. National de Greffe de Moelle Osseuse, Tunis, Tunisia

References Abstract

1. Jacoby GA. Mechanisms of resistance to quinolones. Clin Infect Dis Three isolates of Mycoplasma amphoriforme, a new Mycoplasma 2005; 41 (suppl 2): 120–126. rarely described to date, were obtained from respiratory 2. Cattoir V, Poirel L, Aubert C, Soussy CJ, Nordmann P. Unexpected tract specimens from two children and one adult with respira- occurrence of plasmid-mediated quinolone resistance determinants in tory tract infections. Molecular methods were required to dis- environmental Aeromonas spp. Emer Infect Dis 2008; 14: 231–233. 3. Clinical and Laboratory Standards Institute. Performance for antimicro- tinguish them from Mycoplasma pneumoniae. MICs of macrolides, bial susceptibility testing; 17th informational supplement M100-S17. tetracyclines and fluoroquinolones were identical to those for Wayne, PA: The Institute, 2007. M. pneumoniae, except for that of ciprofloxacin, which was 4. Clinical and Laboratory Standars Institute. Performance for antimicrobial susceptibility testing; 18th informational supplement M100-S18. Wayne, slightly more potent against M. amphoriforme. M. amphoriforme PA: The Institute, 2007. could possibly have been involved in one case of severe respira- 5. Borrell N, Acinas S, Figueras MJ, Martinez-Murcia AJ. Identification of tory infection with sepsis, but further studies are needed to Aeromonas clinical isolates by restriction fragment length polymor- phism of PCR-amplified 16S rRNA genes. J Clin Microbiol 1997; 35: specify its role as a potential respiratory tract pathogen. 1671–1674. 6. Ghatak S, Agarwal RK, Bhilegaonkar KN. Species identification of clinically important Aeromonas spp. by restriction fragment of 16S rDNA. Lett Appl Microbiol 2007; 44: 550–554. 7. Yan˜ez MA, Catala´n V, Apra´iz D, Figueras MJ, Martı´nez-Murcia AJ. Keywords: Human mycoplasma, molecular detection, Phylogenetic analysis of members of the Aeromonas based on Mycoplasma amphoriforme, respiratory tract infection, gyrB gene sequences. Int J Syst Evol Microbiol 2003; 53: 875–883. 8. Cattoir V, Poirel L, Rotimi V, Soussy CJ, Nordmann P. Multiplex PCR susceptibility testing for detection of plasmid-mediated quinolone resistance qnr genes in ESBL-producing enterobacterial isolates. J Antimicrob Chemother 2007; Original Submission: 14 April 2009; Revised Submission: 60: 394–397. 9. Goni-Urriza M, Arpin C, Capdepuy M, Dubois V, Caumette P, Quen- 24 June 2009; Accepted: 3 July 2009 tin C. Type II topoisomerase quinolone resistance-determining Editor: D. Raoult regions of Aeromonas caviae, A. hydrophila, and A. sobria complexes Article published online: 23 September 2009 and mutations associated with quinolone resistance. Antimicrob Agents Chemother 2002; 46: 350–359. 10. Martı´nez-Martı´nez L, Eliecer Cano M, Manuel Rodrı´guez-Martı´nez J, Clin Microbiol Infect 2010; 16: 1007–1009 Calvo J, Pascual A. Plasmid-mediated quinolone resistance. Expert Rev 10.1111/j.1469-0691.2009.02993.x Anti Infect Ther 2008; 6: 685–711. 11. Pica RC, Poirel L, Demarta A et al. Plasmid-mediated quinolone resis- tance in Aeromonas allosaccharophila recovered from a Swiss lake. J Antimicrob Chemother 2008; 62: 948–950. 12. Sa´nchez-Ce´spedes J, Blasco MD, Marti S et al. Plasmid-mediated Corresponding author and reprint requests: S. Pereyre, QnrS2 determinant from a clinical Aeromonas veronii isolate. Antimicrob Laboratoire de Bacte´riologie EA 3671, Mycoplasma and Chlamydia Agents Chemother 2008; 52: 2990–2991. Infections in Humans, Universite´ Victor Segalen Bordeaux 2, 146 rue 13. Young HK. Antimicrobial resistance spread in aquatic environments. Le´o Saignat, 33076 Bordeaux Cedex, France J Antimicrob Chemother 1993; 31: 627–635. E-mail: [email protected]

ª2009 The Authors Journal Compilation ª2009 European Society of Clinical Microbiology and Infectious Diseases, CMI, 16, 1005–1030 1008 Clinical Microbiology and Infection, Volume 16 Number 7, July 2010 CMI

Mycoplasma amphoriforme is a novel human Mycoplasma spe- colonies resembling typical M. pneumoniae colonies. However, cies belonging to the phylogenetic group Pneumoniae [1]. the M. pneumoniae-specific real-time PCR remained negative Only 12 isolates have been reported, mainly from respiratory on all broths. Amplification and sequencing of a 16S rRNA tract specimens of patients with immunological disorders and gene fragment led to approximately 550-bp sequences present- productive cough [2,3]. The mode of acquisition and the ing identities ranging from 98.7% to 99.7% with the 16S rRNA pathogenic role of this species have not yet been established. gene from the M. amphoriforme A39 reference strain. Moreover, However, this organism is unlikely to be a common com- a 550-bp amplification product was obtained with the PCR mensal of the upper respiratory tract, as it has not been targeting the M. amphoriforme 16S rRNA gene [1]. Thus, the detected in healthy persons or asymptomatic patients with identification of three M. amphoriforme clinical isolates, namely primary antibody deficiency [2]. Two difficulties could be Ma3663, Ma4526 and G75, was confirmed. encountered in the diagnosis and treatment of this species. The Ma3663 isolate was cultured from a throat swab of a First, M. amphoriforme may be easily confused with Myco- previously healthy 35-year-old adult hospitalized in 2004 in plasma pneumoniae, the main respiratory tract pathogenic an intensive-care unit of the Bordeaux University Hospital mycoplasma species [1]. Second, it has been suggested that (France) for undocumented severe sepsis with a cutaneous this Mycoplasma species could be resistant to that rash and a bilateral interstitial syndrome on the chest are generally active against [2]. We report the radiograph. Except for M. amphoriforme, no other bacterial detection and the susceptibility testing of three M. amphori- or viral agent was found in his respiratory or blood speci- forme clinical strains, isolated in France and in Tunisia. mens. The Ma4526 isolate, as well as 4 · 106 CFU/mL A bronchoalveolar lavage sample and two throat swabs Haemophilus influenzae, were cultured from the bronchoalve- were grown in Hayflick modified broth medium supple- olar lavage fluid of a French 2-year-old girl hospitalized in mented with glucose [4]. Broths with a colour change were 2007 at the same hospital for an exacerbation of cystic fibro- plated on Hayflick agar medium, and the DNA was extracted sis. The G75 strain and commensal oral were iso- from yellow broths using the MagNA Pure extraction system lated from a throat swab of a Tunisian 2-year-old boy with a (Roche, France). A real-time PCR targeting the M. pneumoniae history of b-thalassaemia major, consulting in 2006 for an P1 adhesin gene was performed on DNA extracts as previ- undocumented productive cough with fever in the Bone ously described [5]. DNA extracts were amplified with prim- Marrow Transplant Centre of Tunis (Tunisia). None of the ers GPO1 and MGSO [6], targeting a conserved fragment of three patients had received any antimycoplasmal the Mycoplasma 16S rRNA genes, and PCR products were treatment before or during the course of their infectious sequenced. Finally, DNA extracts were amplified with prim- syndrome. Moreover, M. pneumoniae serology findings ers amph-F and amph-R, specific to the M. amphoriforme 16S remained negative for all patients. rRNA, as previously described [1]. MICs of macrolides and MICs for the three isolates are presented in Table 1, in related antibiotics, tetracyclines and fluoroquinolones were comparison with those for the M. pneumoniae M129 suscep- determined for the three clinical isolates by a broth dilution tible reference strain. The three isolates were susceptible to method [4]. antibiotics usually active against mycoplasmas. MICs of mac- The three respiratory tract specimens led to a colour rolides and related antibiotics, tetracyclines and fluoroquinol- change of the broth medium from red to yellow, after 15–20 ones were about the same as those for M. pneumoniae, days, indicating acidification and bacterial growth. Plated on except for that of ciprofloxacin, which was more potent agar medium, two of the three broths led to bubble-shaped against M. amphoriforme, with MICs four times lower than

TABLE 1. MICs (mg/L) of macrolides and related antibiotics, tetracyclines and fluoroquinolones for three Mycoplasma amphor- iforme clinical isolates in comparison with those obtained for the Mycoplasma pneumoniae M129 susceptible reference strain

MIC

Mycoplasmal strains ERY AZM JOS CLI PRI TEL TET DOX CIP LEV MOX

M. amphoriforme Ma3663 0.03 0.001 0.008 0.2 0.06 0.001 0.12 0.12 0.25 0.25 0.06 Ma 4526 0.015 0.001 0.008 0.5 0.06 0.002 0.12 0.12 0.25 0.25 0.03 G75 0.015 0.001 0.008 0.5 0.12 0.002 0.12 0.12 0.25 0.12 0.06 M. pneumoniae M129 0.015 0.001 0.015 0.5 0.12 0.001 0.25 0.12 1 0.5 0.06

ERY, erythromycin A; AZM, azithromycin; JOS, josamycin; CLI, clindamycin; PRI, pristinamycin; TEL, telithromycin; TET, tetracycline; DOX, doxycycline; CIP, ciprofloxacin; LEV, levofloxacin; MOX, moxifloxacin.

ª2009 The Authors Journal Compilation ª2009 European Society of Clinical Microbiology and Infectious Diseases, CMI, 16, 1005–1030 CMI Research Notes 1009

that of M. pneumoniae (Table 1). The ciprofloxacin MICs of References 0.25 mg/L for these M. amphoriforme clinical isolates con- trasted with the ciprofloxacin MIC of 1.5 mg/L obtained for 1. Pitcher DG, Windsor D, Windsor H et al. Mycoplasma amphoriforme the M. amphoriforme reference strain A39 with an agar dilu- sp. nov., isolated from a patient with chronic bronchopneumonia. Int J tion method [2]. Unfortunately, this strain was not available Syst Evol Microbiol 2005; 55: 2589–2594. for this difference to be checked. 2. Webster D, Windsor H, Ling C, Windsor D, Pitcher D. Chronic bron- chitis in immunocompromised patients: association with a novel Myco- As previously suggested [1], M. amphoriforme could be plasma species. Eur J Clin Microbiol Infect Dis 2003; 22: 530–534. easily missed and confused with M. pneumoniae by culture, 3. Waites K, Talkington D. New developments in human diseases due to as both of them hydrolyse glucose and lack the characteris- mycoplasmas. In: Blanchard A, Browning GF, eds. Mycoplasmas molecu- lar biology pathogenicity and strategies for control. Wymondham: Horizon tic ‘fried egg’ appearance of many mycoplasmas. In conse- Bioscience, 2005; 289–354. quence, molecular methods were required to distinguish 4. Waites KB, Be´be´ar CM, Roberston JA, Talkington DF, Kenny GE, eds. them. Cumitech 34, Laboratory diagnosis of mycoplasmal infections. Washington, M. amphoriforme was previously described as an opportun- DC: American Society for Microbiology, 2001. 5. Touati A, Benard A, Ben Hassen A, Be´be´ar CM, Pereyre S. Evaluation ist that was probably pathogenic in immunodeficient patients of five commercial real-time PCR assays for the detection of Myco- and did not belong to the commensal respiratory flora [1,3]. plasma pneumoniae in respiratory tract specimens. J Clin Microbiol 2009; Its pathogenic role was reinforced by the study of its deter- 47: 2269–2271. 6. van Kuppeveld FJ, van der Logt JT, Angulo AF et al. Genus- and spe- gent-insoluble structure, which was similar to the electron- cies-specific identification of mycoplasmas by 16S rRNA amplification. dense core of the M. pneumoniae attachment organelle Appl Environ Microbiol 1992; 58: 2606–2615. required for virulence [7]. In our study, two children had an 7. Hatchel JM, Balish RS, Duley ML, Balish MF. Ultrastructure and gliding motility of Mycoplasma amphoriforme, a possible human respiratory underlying immunodepressive disease. However, the clinical pathogen. Microbiology 2006; 152: 2181–2189. significance of the detection of M. amphoriforme was uncer- tain in both cases, as the microbiological information was incomplete, and both children recovered without receiving an antibiotic active against mycoplasmas. In contrast, the First international spread and adult with severe sepsis was a previously healthy person dissemination of the virulent Queensland without any immunological disorder or antecedents. As no community-associated methicillin-resistant other bacterial or viral agent was found, M. amphoriforme Staphylococcus aureus strain could possibly be considered to be involved in his severe infectious syndrome, which resulted in a 2-month stay in an M. J. Ellington1, M. Ganner1, M. Warner2, E. Boakes1, intensive-care unit. Unfortunately, the detection of the myco- B. D. Cookson1, R. L. Hill2 and A. M. Kearns1 plasmal origin was too late for antibiotic treatment active 1) Laboratory of Healthcare Associated Infection and 2) Antibiotic Resis- against mycoplasmas to be started. tance Monitoring and Reference Laboratory, Centre for Infections, Health In conclusion, M. amphoriforme was isolated in respiratory Protection Agency, London, UK specimens from three patients with respiratory tract infec- tions, but molecular methods were required to distinguish it from M. pneumoniae. This species was susceptible to antibiot- Abstract ics that are generally active against mycoplasmas, and was slightly more susceptible to ciprofloxacin than M. pneumoniae. We report the first international spread and dissemination of In this study, M. amphoriforme could possibly be involved in ST93-SCCmecIV (Queensland clone) methicillin-resistant Staphy- one case of severe respiratory infection with sepsis. More- lococcus aureus (MRSA), previously identified in communities and over, to add to the epidemiological knowledge of this species hospitals in Australia. Ten highly genetically related MRSA iso- and to specify its role as a potential respiratory pathogen, lates and one methicillin-susceptible S. aureus (MSSA) isolate further studies on its detection in respiratory tract speci- were identified in England between 2005 and June 2008. The mens with molecular methods are needed. demography and clinical features were typical for community- associated-MRSA. One female with MRSA infection died from necrotizing pneumonia. Travel between Australia and the UK, Transparency Declaration and some onward transmission, suggested that both importation and clonal dissemination of this strain had occurred, albeit to a All authors declare that they have no conflicts of interest, small extent. Nosocomial transmission was not detected, but we financial or other. remain vigilant for further importations and/or spread.

ª2009 The Authors Journal Compilation ª2009 European Society of Clinical Microbiology and Infectious Diseases, CMI, 16, 1005–1030