title: Nosocomial transmission of Mycobacterium bovis resistant to 11 drugs in people with advanced HIV-1 infection.
abstract: BACKGROUND
  Since 1990, several nosocomial outbreaks of multidrug-resistant (MDR) tuberculosis have occurred, none of which have involved Mycobacterium bovis. We describe an epidemic of nosocomial and primary MDR M bovis tuberculosis from December, 1993, to February, 1995, among HIV-1-infected patients in a district of Madrid.
  
  
  METHODS
  We undertook genetic characterisation of the M bovis strain and investigated its presence in a tuberculosis epidemic in a Madrid hospital in a case-controlled study. We assessed 19 cases diagnosed with MDR tuberculosis due to M bovis during the study period. For the control group, we randomly selected 33 patients with HIV-1 infection and isolation of a strain of M tuberculosis susceptible to isoniazid, rifampicin, or both, who were treated in Ramón y Cajal Hospital. Infection-control policies and practices were implemented.
  
  
  RESULTS
  We detected 19 cases in HIV-1-infected patients of primary MDR tuberculosis produced by M bovis resistant to 11 antituberculosis drugs. We found phenotypic and genotypic similarities in the strains of M bovis. In the case group, the index case and two other cases had had previous contact with another hospital that had had an MDR tuberculosis outbreak. All patients died after a mean of 44 days (range 2-116), despite multidrug treatment with first-line and second-line antituberculosis drugs. The cases with M bovis MDR tuberculosis were significantly more likely than controls to have been admitted to a hospital ward at the same time as patients already infected with MDR tuberculosis during the 10 months before their diagnosis (adjusted odds ratio 94.6 [95% CI 9.4-956.3], p < 0.0001). Advanced HIV-1 immunosuppression was associated with the development of MDR tuberculosis. Implementation of control measures stopped the epidemic.
  
  
  CONCLUSIONS
  An M bovis primary MDR tuberculosis epidemic that cannot be treated effectively and with high mortality has emerged in Europe and has been transmitted between hospitals.
authors.affiliation: Infectious Disease and Clinical Microbiology Department, Hospital Ramón y Cajal, Universidad de Alcalá de Henares, Madrid, Spain. antonio.guerrero@hrc.es
authors.forename: A
authors.initials: A
authors.lastname: Guerrero
authors.forename: J
authors.initials: J
authors.lastname: Cobo
authors.forename: J
authors.initials: J
authors.lastname: Fortún
authors.forename: E
authors.initials: E
authors.lastname: Navas
authors.forename: C
authors.initials: C
authors.lastname: Quereda
authors.forename: A
authors.initials: A
authors.lastname: Asensio
authors.forename: J
authors.initials: J
authors.lastname: Cañón
authors.forename: J
authors.initials: J
authors.lastname: Blazquez
authors.forename: E
authors.initials: E
authors.lastname: Gómez-Mampaso
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000453:epidemiology / Q000382:microbiology / Q000635:transmission*; D000328:Adult; D000995:Antitubercular Agents / Q000494:pharmacology* / Q000627:therapeutic use; D018791:CD4 Lymphocyte Count; D016022:Case-Control Studies; D003428:Cross Infection / Q000453:epidemiology / Q000382:microbiology / Q000635:transmission; D004196:Disease Outbreaks / Q000517:prevention & control; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000382:microbiology; D015497:HIV-1; D006801:Humans; D017053:Infection Control / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009163:Mycobacterium bovis / Q000145:classification* / Q000187:drug effects / Q000302:isolation & purification; D009169:Mycobacterium tuberculosis / Q000187:drug effects / Q000302:isolation & purification; D013030:Spain / Q000453:epidemiology; D018088:Tuberculosis, Multidrug-Resistant / Q000453:epidemiology / Q000382:microbiology / Q000635:transmission*
chemical_list: D000995:Antitubercular Agents