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Recommendations of first choice antibiotic therapy need to be based on actual antibiotic susceptibility data. We determined the antibiotic susceptibility of E. coli in uncomplicated UTI among women and compared the results with 2004 and 2009. In 30 sentinel general practitioner practices of Nivel Primary Care database, urine samples were collected from women with symptoms of uncomplicated UTI. Patient characteristics, E. coli susceptibility, and ESBL production were analyzed. Six hundred eighty-nine urine samples were collected; E. coli was the most isolated uropathogen (83%). Antibiotic susceptibility was stable over time except for ciprofloxacin (96% in 2004, 97% in 2009, and 94% in 2014; P 70 years (P = 0.005). In 2014, prescription of fosfomycin increased compared to 2009 (14.3% versus 5.6%) at the expense of co-amoxiclav, co-trimoxazole, and fluoroquinolones (P

Purpose The aim of this study was to assess the feasibility of obtaining nasal and rectal swabs from general practice patients for measuring carriage of antibiotic resistant microorganisms in an area in Rotterdam (the Netherlands) with low socioeconomic status and a large immigrant population. Methods Data collection was from May to December 2017, in one general practice in Rotterdam. We asked adults (≥18 years) visiting the general practitioner (GP) with complaints not related to infections for one nasal and two rectal swabs and tested these for highly resistant microorganisms (HRMOs). Indicators for feasibility were recruitment rate, implementation and acceptation of data collection procedures by the participants. Results We obtained a nasal swab from all included 234 patients and 164 (70%) also gave rectal swabs. On average, 3 out of 30 invited patients (10%) were recruited per day. The GPs considered the workload high to inform and refer to eligible patients for the study and did this inconsistently. Most participants experienced the rectal swab procedure as burdensome and preferred assistance of a medical assistant above self-swabbing. A monetary incentive increased the willingness to provide rectal swabs. Conclusions Obtaining (nasal and) rectal swabs from general practice patients for study purposes proved difficult. Lessons learnt from this feasibility study will help increase participation in HRMO prevalence studies among asymptomatic general practice patients.

OBJECTIVES: Matrix-assisted laser desorption/ionization-time of flight mass spectrometry (MALDI-TOF MS) is becoming the method of choice for bacterial identification. However, correct identification by MALDI-TOF of closely related microorganisms such as viridans streptococci is still cumbersome, especially in the identification of S. pneumoniae. By making use of additional spectra peaks for S. pneumoniae and other viridans group streptococci (VGS). We re-identified viridans streptococci that had been identified and characterized by molecular and phenotypic techniques by MALDI-TOF.METHODS: VGS isolates (n = 579), 496 S. pneumoniae and 83 non-S. pneumoniae were analysed using MALDI-TOF MS and the sensitivity and specificity of MALDI-TOF MS was assessed. Hereafter, mass spectra analysis was performed. Presumptive identification of proteins represented by discriminatory peaks was performed by molecular weight matching and the corresponding nucleotides sequences against different protein databases.RESULTS: Using the Bruker reference library, 495 of 496 S. pneumoniae isolates were identified as S. pneumoniae and one isolate was identified as non-S. pneumoniae. Of the 83 non-S. pneumoniae isolates, 37 were correctly identified as non-S. pneumoniae, and 46 isolates as S. pneumoniae. The sensitivity of the MALDI-TOF MS was 99.8% (95% confidence interval (CI) 98.9-100) and the specificity was 44.6% (95% CI 33.7-55.9). Eight spectra peaks were mostly present in one category (S. pneumoniae or other VGS) and absent in the other category and inversely. Two spectra peaks of these (m/z 3420 and 3436) were selected by logistic regression to generate three identification profiles. These profiles could differentiate between S. pneumoniae and other VGS with high sensitivity and specificity (99.4% and 98.8%, respectively).CONCLUSIONS: Spectral peaks analysis based identification is a powerful tool to differentiate S. pneumoniae from other VGS species with high specificity and sensitivity and is a useful method for pneumococcal identification in carriage studies. More research is needed to further confirm our findings. Extrapolation of these results to clinical strains need to be deeply investigated.

Wereldwijd raken steeds meer mensen geinfecteerd door extended-spectrumbetalactamase (ESBL) producerende bacterien. Zagen we ESBL-infecties aanvankelijk vooral in ziekenhuizen, nu krijgen ook huisartsen ermee te maken. Dit komt door de veranderde samenstelling van de (patienten) populatie en doordat ziekenhuiszorg zich verplaatst naar de huisarts. Bij een infectie door een ESBL-producerende bacterie (EPB) kan de standaardbehandeling niet aanslaat. Huisartsen moeten hierop bedacht zijn als een standaardbehandeling bij infecties faalt en risicofactoren voor dragerschap van EPB aanwezig zijn. Samenwerking tussen de eerste en tweede lijn is essentieel voor de aanpak van dit groeiende probleem.

Aim: Increasing antimicrobial resistance (AMR) requires rapid surveillance tools, such as Lot Quality Assurance Sampling (LQAS). Materials & methods: LQAS classifies AMR as high or low based on set parameters. We compared classifications with the underlying true AMR prevalence using data on 1335 Escherichia coli isolates from surveys of community-acquired urinary tract infection in women, by assessing operating curves, sensitivity and specificity. Results: Sensitivity and specificity of any set of LQAS parameters was above 99% and between 79 and 90%, respectively. Operating curves showed high concordance of the LQAS classification with true AMR prevalence estimates. Conclusion: LQAS-based AMR surveillance is a feasible approach that provides timely and locally relevant estimates, and the necessary information to formulate and evaluate guidelines for empirical treatment.

Item does not contain fulltext Objectives: : Residents living in a long-term care facility (LTCF) are more susceptible to infections. Treatment with antimicrobials is sometimes necessary; however, antibiotic use is considered one of the most important drivers of the development of antibiotic resistance. Surveillance data on antibiotic use in these LTCFs are necessary to get more insight into these patterns. The objective of this study was to describe antibiotic use in LTCFs in the Netherlands. Methods: : One hundred and seventy-seven LTCFs in the Netherlands were contacted and asked to participate in a study concerning antibiotic resistance and antibiotic use. Associated pharmacies were asked to provide data about systemic antibiotic use for each participating LTCF location over 1 year. Results on antibiotic use are reported here. Results: : Antibiotic use data from 96 LTCFs were collected from the pharmacies, and 68 of these LTCFs completed additional questionnaires on general characteristics of their location. Mean total use of systemic antimicrobials was 73 DDDs/1000 residents per day (range 2-197 DDDs/1000 residents per day). Co-amoxiclav (23 DDDs/1000 residents/day, range 0-70) was used the most, followed by nitrofurantoin derivatives (12 DDDs/1000 residents/day, range 0-38) and fluoroquinolones (12 DDDs/1000 residents/day, range 0-52). Statistical analysis revealed no significant correlations between the LTCF characteristics and the level of antibiotic use. Conclusions: There was a high use of broad-spectrum antimicrobials, with a large variation in total antibiotic use between individual locations. Further analysis of more in-depth data and possible influencing factors is needed.

Antimicrobial resistance (AMR) is an increasing problem. The prevalence of antimicrobial resistance in general practice patients is expected to be relatively high in Rotterdam, the Dutch city with the largest proportion non-Western immigrants. The aim of this study was to assess the prevalence of antibiotic-resistant uropathogens (Escherichia coli,Klebsiella pneumoniae, andProteus mirabilis) in general practices in Rotterdam, and to find a possible association between the prevalence of antibiotic-resistantE. coliand age, gender, and socioeconomic status (SES). A retrospective analysis was performed of urine samples from general practice patients in 2016. The prevalence of AMR in uropathogens was compared with national resistance data, as was the prevalence of highly and multidrug resistant and extended spectrum β-lactamase (ESBL) producingE. coliandK. pneumoniae.Univariate logistic regression was used to study associations between antibiotic-resistantE. coliand age, gender, and SES area score. No clinically relevant differences were observed in the prevalence of antibiotic-resistant uropathogens in Rotterdam compared with the national prevalence. ForE. coliandK. pneumoniae, the prevalence was 3.6% for ESBL production (both pathogens together), while the prevalence ranged between 4.2%–5.0% for high resistance and between 1.2%–3.3% for multidrug resistance. Ciprofloxacin-resistantE. coliwas significantly associated with higher age. Although Rotterdam has a high percentage of non-western immigrants and a low SES, AMR is low among general practice patients. This indicates that adherence to national guidelines in general practice enables maintenance of low AMR, even in high-risk populations.

Aim: To evaluate whether intestinal microbiota predicts the development of new-onset urinary tract infections (UTIs) in postmenopausal women with prior recurrent UTIs (rUTIs). Patients & methods: Fecal samples (n = 40) originated from women with rUTI who received 12 months’ prophylaxis of either trimethoprim–sulfamethoxazole (TMP–SMX) or lactobacilli. Microbial composition was assessed by 16S rRNA pyrosequencing. Results: At baseline, fecal microbiota of women with zero and more than or equal to four UTIs during follow-up showed no significant differences. Only TMP–SMX prophylaxis resulted in reduced microbial diversity. Microbial structure of two samples from the same woman showed limited relatedness. Conclusion: In postmenopausal women with rUTI, the intestinal microbiota was not predictive for new-onset UTIs. Only TMP–SMX, and not lactobacilli, prophylaxis had effects on the microbial composition. Data in ENA:PRJEB13868.

Item does not contain fulltext The human microbiota represents an important reservoir of antibiotic resistance. Moreover, the majority of antibiotics are prescribed in primary care. For this reason, we assessed the prevalence and antibiotic resistance of nasal carriage strains of Streptococcus pneumoniae, the most prevalent bacterial causative agent of community-acquired respiratory tract infections, in outpatients in nine European countries. Nasal swabs were collected between October 2010 and May 2011, from 32,770 patients, recruited by general practices in nine European countries. Overall prevalence of S. pneumoniae nasal carriage in the nine countries was 2.9%. The carriage was higher in men (3.7%) than in women (2.7%). Children (4-9 years) had a higher carriage prevalence (27.2%) compared with those older than 10 years (1.9%). The highest resistance observed was to cefaclor. The highest prevalence of multidrug resistance was found in Spain and the lowest prevalence was observed in Sweden.

Aim: The objective of this study is to compare various Streptococcus pneumoniae identification methods. Materials & methods: In total, 1371 putative S. pneumoniae isolates were tested with three phenotypic methods and a molecular-based method targeting a virulence factor (CpsA). We assessed the sensitivity and the specificity of each method and widely used S. pneumoniae identification algorithm. Results: None of the methods or the identification algorithm used separately was able to correctly identify all S. pneumoniae isolates. Furthermore, a high rate of optochin resistance was found. Conclusions: We demonstrated the failure of the current S. pneumoniae identification methods and optochin susceptibility-based algorithm. In addition, the high rate of optochin resistance might justify the necessity of a close monitoring of optochin susceptibility.

Background Exhaled breath analysis is an emerging technology in respiratory disease and infection. Electronic nose devices (e-nose) are small and portable with a potential for point of care application. Ventilator-associated pneumonia (VAP) is a common nosocomial infection occurring in the intensive care unit (ICU). The current best diagnostic approach is based on clinical criteria combined with bronchoalveolar lavage (BAL) and subsequent bacterial culture analysis. BAL is invasive, laborious and time consuming. Exhaled breath analysis by e-nose is non-invasive, easy to perform and could reduce diagnostic time. Aim of this study was to explore whether an e-nose can be used as a non-invasive in vivo diagnostic tool for VAP. Methods Seventy-two patients met the clinical diagnostic criteria of VAP and underwent BAL. In thirty-three patients BAL analysis confirmed the diagnosis of VAP [BAL+(VAP+)], in thirty-nine patients the diagnosis was rejected [BAL−]. Before BAL was performed, exhaled breath was sampled from the expiratory limb of the ventilator into sterile Tedlar bags and subsequently analysed by an e-nose with metal oxide sensors (DiagNose, C-it, Zutphen, The Netherlands). From further fifty-three patients without clinical suspicion of VAP or signs of respiratory disease exhaled breath was collected to serve as a control group [control(VAP−]). The e-nose data from exhaled breath were analysed using logistic regression. Results The ROC curve comparing [BAL+(VAP+)] and [control(VAP−)] patients had an area under the curve (AUC) of 0.82 (95% CI 0.73–0.9). The sensitivity was 88% with a specificity of 66%. The comparison of [BAL+(VAP+)] and [BAL−] patients revealed an AUC of 0.69; 95% CI 0.57–0.81) with a sensitivity of 76% with a specificity of 56%. Conclusion E-nose lacked sensitivity and specificity in the diagnosis of VAP in the present study for current clinical application. Further investigation into this field is warranted to explore the diagnostic possibilities of this promising new technique.

Aim: To determine whether bacteriological analysis of a wound swab is supportive in the clinical assessment of infection of a chronic wound. Methods: Patients attending an outpatient wound clinic who had endured a chronic wound for more than 3 weeks were clinically assessed for infection. In addition, standardized wound swabs were taken according to the Levine technique and the microbiological findings of the swabs compared with the clinical assessment of the wounds. Results: There was no significant relationship between the clinical assessments of the chronic wounds and the qualitative or quantitative bacteriological results of the swabs. Conclusion: Microbiological analysis of wound swabs taken from chronic wounds to support clinical assessment of the wounds is waste of time and money. It may be preferable to assess chronic wounds clinically, however, validation studies of these signs and symptoms are needed.

Objective: To perform, from an insurance perspective, a cost analysis of one of the outpatient community wound care clinics in the Netherlands, the Knowledge Centre in Wound Care (KCWC) at Venray. Method: This study involved a cost analysis based on an observational cohort study with a one-year pre-admission and a one-year post-admission comparison of costs. Patients were included when they first consulted the outpatient wound care clinic. Participants were all insured by the same health insurance company, Coöperatie Volksgezondheidszorg (VGZ). A standard six-step procedure for performing cost studies was used to calculate the costs. Given the skewed cost data, non-parametric bootstrapping was used to test for statistical differences. Results: There were 172 patients included in this study. The difference in costs related to wound care between the year before and the year after initial admission to the wound clinic amounted to an average reduction of €2621 (£1873) per patient in the base case analysis. The categories ‘general practitioner’, ‘hospital care’, ‘mental health care’ and ‘transport’ scored lower, indicating lower costs, in the year after admission to the wound clinic. Conclusion: In this study, only the reimbursement data of patients of one health insurance company, and specifically only those made under the 2006 Dutch Health Insurance Act, were available. Because of the observational design, definitive conclusions cannot be made regarding a demonstrated reduction of costs in the year post admission. Nevertheless, this study is a first attempt of a cost analysis of an equipped outpatient wound clinic as an innovative way of responding to the increasing number of chronic wounds in the Netherlands. The calculations show that savings in wound care are possible. Declaration of interest: A possible conflict of interest should be mentioned. First author AALM Rondas, PhD student at Maastricht University, is working at the KCWC wound clinic at Venray in the Netherlands as a physician. However, the research data were provided externally by Coöperatie Volksgezondheidszorg (VGZ) and checked by the academic co-authors, none of whom have a conflict of interest. The authors have no financial or commercial interest to declare.

To understand the dynamics behind the worldwide spread of the mcr-1 gene, we determined the population structure of Escherichia coli and of mobile genetic elements (MGEs) carrying the mcr-1 gene. After a systematic review of the literature we included 65 E. coli whole genome sequences (WGS), adding 6 recently sequenced travel related isolates, and 312 MLST profiles. We included 219 MGEs described in 7 Enterobacteriaceae species isolated from human, animal and environmental samples. Despite a high overall diversity, 2 lineages were observed in the E. coli population that may function as reservoirs of the mcr-1 gene, the largest of which was linked to ST10, a sequence type known for its ubiquity in human faecal samples and in food samples. No genotypic clustering by geographical origin or isolation source was observed. Amongst a total of 13 plasmid incompatibility types, the IncI2, IncX4 and IncHI2 plasmids accounted for more than 90% of MGEs carrying the mcr-1 gene. We observed significant geographical clustering with regional spread of IncHI2 plasmids in Europe and IncI2 in Asia. These findings point towards promiscuous spread of the mcr-1 gene by efficient horizontal gene transfer dominated by a limited number of plasmid incompatibility types.

Den Heijer CDJ, Van Dongen MCJM, Donker GA, Stobberingh EE. Diagnostiek van urineweginfecties bij mannen. Huisarts Wet 2014;57(8):390-4. De diagnostiek van urineweginfecties bij mannen leidt mogelijk tot overbehandeling in de huisartsenpraktijk. Wij formuleerden een beslisregel op basis van een dipsticktest en leeftijd (ouder dan 60 jaar), en gingen na in hoeverre die regel het beleid beinvloedde ten opzichte van de gebruikelijke praktijk. Surveillanceonderzoek binnen de peilstations van NIVEL Zorgregistraties eerste lijn over de periode van januari 2009 tot juli 2011. Via de participerende huisartsen verzamelden wij dipstickresultaten en overige klinische informatie. Bij 103 kolonievormende eenheden per ml urine beschouwden wij de urineweginfectie (UWI) als microbiologisch bevestigd. Wij vergeleken de sensitiviteit en de specificiteit van de beslisregel met die van de gebruikelijke zorg (antibiotica bij een bevestigde urineweginfectie, geen antibiotica bij een niet-bevestigde urineweginfectie). Wij beschikten over de complete gegevens van 490/603 (81%) mannen. Bij 321/490 (66%) werd een UWI bevestigd. De beslisregel adviseert een antibioticum voor te schrijven aan patienten met een positieve nitriettest en aan patienten ouder dan 60 jaar met een positieve leukocytenesterasetest. Bij negatieve testuitslagen was de kans op een UWI 40%, bij mannen jonger dan 60 jaar 29%. De sensitiviteit en de specificiteit van de beslisregel weken niet significant af van die van gebruikelijke zorg: respectievelijk 75% versus 79%, en 70% versus 63% (beide p > 0,05). In de praktijk verbetert de door ons opgestelde beslisregel de diagnostiek van urineweginfecties bij mannen niet. Wanneer er ondanks een negatieve dipstick toch enige verdenking op een urineweginfectie blijft bestaan, volstaat een afwachtend empirisch antibioticumbeleid aangezien de kans op een infectie relatief klein is.

Objectives/HypothesisElectronic nose (E-nose) technology has various applications such as the monitoring of air quality and the detection of explosive and chemical agents. We studied the diagnostic accuracy of volatile organic compounds (VOC) pattern analysis in exhaled breath by means of an E-nose in patients with head and neck squamous cell carcinoma (HNSCC).Study DesignCohort study. Exhaled breath samples from patients with HNSCC were analyzed by using an E-Nose.MethodsThirty-six patients diagnosed with HNSCC exhaled into a 5-litre Tedlar bag. The control group consisted of 23 patients visiting the outpatient clinic for other (benign) conditions. Air samples were analyzed using an E-nose.ResultsLogistic regression showed a significant difference (P ConclusionsE-nose application holds a promising potential for application in the diagnosis of HNSCC due to its rapid, simple, and noninvasive nature.

Objectives: To determine the prevalence and genetic background of methicillin-sensitive (MSSA) and methicillin-resistant Staphylococcus aureus (MRSA) obtained from healthy food handlers admitted to the Cantonal Public Health Institute of Zenica, Bosnia and Herzegovina, during 2007-2009. Methods: S. aureus were isolated and identified using standard microbiological methods including coagulase and catalase tests. Antibiotic susceptibility testing by disc diffusion method was performed according to the CLSI guidelines. Methicillin resistance was confirmed by the presence of the mecA gene by PCR. The genetic characterization was performed using spa-typing and BURP algorithm. Results: A total of 189 non-duplicated S. aureus isolates were collected from 13 690 nasal swabs (1.4%), of which three were MRSA (1.6%). Among 173 MSSA analyzed, 66 spa types were clustered into nine spa-CCs, four no founders, and singletons. The MSSA spa-CC015 associated with MLST CC45 was predominant, having 41 (24%) strains. All three MRSA were associated with MLST 152 (spa-CC 355/595) which was not found in MSSA isolates. MRSA-related background had 60% MSSA isolates. There were 127 (71%) MSSA and one MRSA sensitive to all antibiotic tested (the beta-lactam compounds excepted); multi-drug resistance was found in 13 (7.3%) of MSSA. Conclusion: Very low prevalence of S. aureus, as well as MRSA was noted. MSSA were more heterogeneous than MRSA. Although the number of MSSA with a genetic background common to MRSA clones was high, the prevalence of MRSA was low, and MLST CC152 of MRSA was not found among MSSA isolates suggesting that MRSA did not arise from predominant MSSA clones.

To the Editor: The susceptibility to asthma development in childhood is influenced by genetic as well as environmental factors, and interactions between these factors [1–3]. However, at present, their exact role is still largely undetermined. Genetic variations in the innate immune system may lead to different adaptive immune responses to bacteria and may therefore vary the development of asthma [2, 4, 5]. We performed a prospective longitudinal study in preschool children, in which we determined polymorphisms in Toll-like receptors ( TLR s) and CD14 , the presence of bacteria, and the proportion of regulatory T-cells (Treg) all in relation to an asthma diagnosis at 6 years of age. We hypothesise that specific genetic variants in genes that affect the innate immune system influence the response to bacteria and the recruitment of Treg in preschool children, leading to an increased likelihood of asthma at 6 years of age. The Asthma DEtection and Monitoring (ADEM) study is a long-term prospective case–control study. A detailed protocol of this study has previously been published [6]. A total of 202 children who had experienced at least two wheezing episodes during their lifetime (International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire) [7] and 50 children without wheezing episodes were included at 2–4 years of age. The children were randomly selected from a random population sample in Limburg, the Netherlands, based on the presence or absence of recurrent wheeze [6]. During the initial visit, saliva or buccal cells (DNA), nasal and throat swabs (bacterial cultures), and blood (Treg) were collected. Participants were genotyped for six single nucleotide polymorphisms in TLR2 , TLR4 , TLR9 and CD14 (Sequenom …

Background: Recently, the first plasmid-mediated colistin-resistance gene, mcr-1, was reported. Colistin is increasingly used as an antibiotic of last resort for the treatment of infections caused by carbapenem-resistant bacteria, which have been rapidly disseminating worldwide in recent years. Objectives: The reported carriage rate of mcr-1 in humans remains sporadic thus far, except for those reported in Chinese populations. We aimed to determine its presence in the faecal metagenomes of healthy Dutch travellers between 2010 and 2012. Methods: Faecal metagenomic DNA of pre-and post-travel samples from 122 healthy Dutch long-distance travellers was screened for the presence of mcr-1 using a TaqMan quantitative PCR assay, which was designed in this study. All positive samples were confirmed by sequencing of the amplicons. Results: The mcr-1 gene was detected in 6 (4.9%, 95% CI = 2.1%-10.5%) of 122 healthy Dutch long-distance travellers after they had visited destinations in South(-east) Asia or southern Africa between 2011 and 2012. One of these participants was already found to be positive before travel. Conclusions: Our study highlights the potential of PCR-based targeted metagenomics as an unbiased and sensitive method to screen for the carriage of the mcr-1 gene and suggests that mcr-1 is widespread in various parts of the world. The observation that one participant was found to be positive before travel suggests that mcr-1 may already have disseminated to the microbiomes of Dutch residents at a low prevalence, warranting a more extensive investigation of its prevalence in the general population and possible sources.

Aims: To determine the incidence and risk factors for surgical site infections (SSI) after vascular surgery, to evaluate the Dutch safety bundle to reduce adverse complications and to analyze causative microorganisms of SSIs. Materials & methods: The 3.5-year study was divided into two periods: the control period (before bundle implementation) and intervention period (after implementation). Postdischarge surveillance was performed until 30 days after surgery. Causative microorganisms from in-hospital wound swabs were determined. SSI rates between both periods were compared and a risk analysis was carried out by performing a logistic regression. Results: The study included 1719 operations. The in-hospital SSI rate increased significantly over time. Out of 140 SSIs, 39% were diagnosed postdischarge. Risk factors were diabetes, age >60 years and operations classified as contaminated or dirty. Pseudomonas aeruginosa susceptibility was the highest for gentamicin (97%). All Staphylococcus aureus were methicillin susceptible. Conclusion: As patient demographics are important to determine the effectiveness of infection preventive measures, (postdischarge) surveillance is important for developing SSI interventions.

The aim of this study was to measure the prevalence of (infected) chronic wounds in Dutch nursing homes and to explore which signs and symptoms are used to diagnose infected chronic wounds. Moreover, it was to determine which structural quality indicators related to chronic wound care at ward and institutional levels were fulfilled. In April 2012, as part of the annual National Prevalence Measurement of Care Problems of Maastricht University [Landelijke Prevalentiemeting Zorgproblemen (LPZ)], a multi-center cross-sectional point-prevalence measurement was carried out together with an assessment of relevant care quality indicators. The prevalence was 4·2%; 16 of 72 (22%) chronic wounds were considered to be infected. Increase of exudate (81·3%; n = 13), erythema (68·8%; n = 11), pain (56·3%; n = 9) and wound recalcitrance (56·3%; n = 9) were considered to be diagnostic signs and symptoms of a chronic wound infection. Although at institutional level most quality indicators were fulfilled, at ward level this was not the case. Despite the relatively low number of residents, we consider our population as representative for the nursing home population. It may be an advantage to appoint specific ward nurses and to provide them specifically with knowledge and skills concerning chronic wounds.

BACKGROUND: Respiratory tract infections (RTI) are frequently caused by Haemophilus influenzae. Widespread antibacterial resistance among respiratory microorganisms complicates empirical RTI treatment. Therefore, national data on antibiotic resistance for H. influenzae are important for guiding optimal antibiotic choice. METHODS: The antibiotic susceptibility of H. influenzae strains isolated from respiratory specimens of patients admitted to the pulmonology services between 2005 and 2010 was assessed. Isolates were collected annually from 13 hospitals in the Netherlands as part of the national intramural antimicrobial resistance surveillance performed by the Dutch Working Group on Antibiotic Policy (SWAB). Breakpoints for resistance were in accordance with the criteria of the European Committee on Antimicrobial Susceptibility Testing (EUCAST). Trend analysis was performed using logistic regression analysis. RESULTS: In total, 1606 H. influenzae strains were analyzed. The prevalence of antibiotic resistance to amoxicillin, co-amoxiclav, doxycycline, co-trimoxazole, and clarithromycin was stable over the 6-y period, and there was a trend towards a decrease in the prevalence of beta-lactamase-producing isolates. Regarding prevalences, no significant trends were observed. CONCLUSIONS: Our study showed no significant changes in antibiotic resistance for H. influenzae isolated at different hospitals in the Netherlands over a 6-y period. Regular surveillance remains important in controlling the prevalence of resistance, since actual resistance data should be taken into account when the choice of an empiric antibiotic is made.

The purpose of this study was the evaluation of trends in the antimicrobial resistance of Pseudomonas aeruginosa from intensive care unit (ICU) patients and urology patients in the Netherlands. From 1998 to 2010, 1,927 consecutive P. aeruginosa isolates from ICU (n = 1,393) and urology service patients (n = 534) of 14 university and referral hospitals all over the Netherlands were collected and their susceptibility to relevant antibiotics was determined according to the European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines. Over time, a significant upward trend in the resistance of P. aeruginosa strains collected from ICUs to piperacillin (1.2 % to 10.6 %, p = 0.0175), piperacillin-tazobactam (1.2 % to 12.1 %, p = 0.0008), ceftazidime (1.2 % to 7.8 %, p = 0.0064), cefepime (4.8 % to 6.4 %, p = 0.0166), imipenem (6 % to 19.1 %, p

Item does not contain fulltext Guideline recommendations on empirical antibiotic treatment are based on the literature, expert opinion, expected pathogens and resistance data, but their adequacy in the real-life setting is often unknown. We investigated the adequacy of the Dutch evidence-based guideline-recommended treatment options for patients with complicated urinary tract infections (UTIs) 2 years after guideline publication and, additionally, the adequacy of actually prescribed empirical therapy for patients treated with guideline-adherent versus non-guideline-adherent therapy. A retrospective, observational multicentre study in the Netherlands included 810 patients with a complicated UTI without special conditions and 174 with a urinary catheter. The susceptibility patterns of cultured uropathogens were compared with guideline-recommended treatment options, which included specific recommendations for patients with a catheter, and with actually prescribed empirical therapy. We considered inadequate coverage rates below 10 % as acceptable. Of the recommended regimens for patients with a UTI without other conditions, only the guideline-recommended combination of amoxicillin-gentamicin was acceptable (inadequate coverage rate 6 %). For patients with a catheter, inadequate coverage rates of recommended regimens ranged from 3 to 24 %. In patients with a UTI without other conditions, actually prescribed guideline-adherent therapy resulted in less broad-spectrum but not in less adequate therapy; in patients with a catheter, actually prescribed guideline-adherent therapy resulted in a higher coverage rate than those prescribed non-guideline-adherent therapy. Due to the continuously changing resistance rates and differences between the epidemiologies of uropathogens assumed in the guideline and those in real life, regular real-life assessments of recommended treatment options are necessary. Guideline adherence seems to be effective for increasing coverage rates without prescribing unnecessarily broad regimens.

Item does not contain fulltext OBJECTIVES: The objective of this study was to assess carriage of antimicrobial-resistant commensal microorganisms, i.e. Escherichia coli and Staphylococcus aureus, and its predictors in long-term-care facilities (LTCFs). METHODS: Nasal swabs and/or urine or incontinence samples were collected from participating residents in 111 LTCFs and tested for the presence of S. aureus and/or E. coli, respectively. Antimicrobial resistance to eight antimicrobials was linked to antimicrobial usage in the year preceding sampling and to LTCF characteristics. Using multilevel logistic regression, predictors of carriage of ESBL-producing E. coli in LTCFs were identified. RESULTS: S. aureus was identified in 1269/4763 (26.6%) nasal swabs, including 13/4763 (0.3%) MRSA carriers in 9/107 (8%) LTCFs. Of the 5359 urine/incontinence samples, 2934 (55%) yielded E. coli, including 123 (4.2%) producing ESBL, which were found in 53/107 locations (range 1%-33%). For all but one antimicrobial (i.e. nitrofurantoin) >20% of isolated E. coli were resistant. Multilevel multivariable logistic regression identified two predictors of carriage of ESBL-producing E. coli: (i) antimicrobial usage (OR 1.8, 95% CI 1.1-3.0 for each extra 50 DDD/1000 residents/day); and (ii) presence of MRSA carriers in the LTCFs (OR 2.4, 95% CI 1.0-5.6). CONCLUSIONS: The low proportion of 4.2% ESBL-producing E. coli and the low prevalence of 0.3% MRSA carriage found in LTCF residents suggest that Dutch LTCFs are not yet an important reservoir of MDR potential pathogens. Nevertheless, the large variation between LTCFs warrants close monitoring of antimicrobial resistance in LTCFs. Integrated surveillance, i.e. linking data sources on antimicrobial usage, microbiological testing, clinical background data and epidemiological data, is needed.

Objectives: Methicillin-resistant Staphylococcus aureus (MRSA) infections are of worldwide concern. The present study describes the antimicrobial resistance and molecular typing of methicillin-resistant and methicillin-susceptible S. aureus (MSSA) bloodstream isolates in Peru.Methods: Consecutive non-duplicate S. aureus bloodstream isolates were collected over a 15month period (2008-2009) from seven hospitals in Lima and Callao, two contiguous cities in Peru. Detection of mecA gene, spa typing and Staphylococcal Chromosomal Cassette (SCC) mec typing were performed. Antimicrobial resistance was assessed by disk diffusion.Results: Of 338 isolates, MRSA rate was 50.0%. Among MRSA isolates (n = 169), 81.7% were associated to MLST CC5, 68.8% had spa t149/SCCmec I, and more than 85% were co-resistant to ciprofloxacin, clindamycin, erythromycin and gentamicin; 8.9% (n = 15) were associated to MLST CC8, 14 of them had spa t148/SCCmec IV, and more than 70% were co-resistant to ciprofloxacin, clindamycin and erythromycin. Among MSSA isolates (n = 169), there was a higher diversity of spa types (n = 56) compared to MRSA isolates (n = 17), 27.2% were associated to MLST CC8, 23.7% were resistant to erythromycin and clindamycin resistance exceeded 20%.Conclusions: MRSA rate among bloodstream isolates in Peru was 50%, with MLST CC5/t149/SCCmec I representing the most frequent clone. (c) 2012 The British Infection Association. Published by Elsevier Ltd. All rights reserved.

Background:Diagnostic urinary tract infection (UTI) studies have primarily been performed among female patients.Aim:To create a diagnostic algorithm for male general practice patients suspected of UTI.Design and setting:Surveillance study in the Dutch Sentinel General Practice Network.Method:Clinical information and dipstick results were collected from 603 patients. Algorithm-predicted care was compared with care as usual in terms of sensitivity (antibiotic recommended when UTI was confirmed) and specificity (no antibiotic recommended when no UTI was observed).Results:Complete information was available from 490/603 (81 %) males, of whom 66 % (321/490) had a UTI. A diagnostic algorithm recommending antimicrobial prescription in the case of a positive nitrite test or a positive leukocyte esterase test in males aged >= 60 years, had a positive predictive value (PPV) of 83 % (95 % confidence interval [CI] = 78 to 87) and a negative predictive value (NPV) of 60 % (95 % CI = 52 to 66), respectively (area under the ROC curve: 0.78, 95 % CI = 0.74 to 0.82). When both dipstick results were positive in males aged >= 60 years, PPV increased to 90 % (95 % CI = 83 to 94), whereas NPV was highest in males >= 60 years with negative dipstick results (71 %, 95 % CI = 59 to 81). Sensitivity and specificity of predicted UTI care and usual care did not differ (75 % versus 79 %, P = 0.30, and 70 % versus 63 %, P = 0.17, respectively).Conclusion:UTI care provided to Dutch male GP patients is as accurate as predicted care from a diagnostic algorithm. The studied clinical information and dipstick tests are useful for ruling in UTI in males, but have limited value in ruling out this diagnosis.

Percutaneous (skin-penetrating) catheters such as central venous catheters (CVCs), are used ubiquitously in the treatment of critically ill patients, although it is known that the risks for serious complications, particularly bloodstream infection and thromboembolism, are high. Materials science and engineering offer important new perspectives regarding further improvement of CVCs. A promising approach is the use of synthetic biocompatible hydrogel coatings with both silver particles and heparin embedded therein. Such formulations combine the well-known broad-spectrum antimicrobial features of silver with the anticoagulant activity of immobilized heparin. Previous work revealed that heparin augments antimicrobial activity of silver, while maintaining its anticoagulant function. This study set out to investigate the synergy of heparin and silver in more detail. Exit-challenge tests, experiments on bacterial killing and adherence, as well as in vitro challenge tests with three Staphylococcus aureus strains (one reference strain, and two clinical isolates) consistently showed the synergistic effect. In addition, the impact of changing the coating's hydrophilicity, and changing the silver concentration in the coatings, were examined. The experimental results, taken together and combined with data from the literature, point out that synergy of heparin and silver is best explained by binding of Ag(+) ions to heparin within the swollen coating, followed by release of heparin-Ag(+) complexes upon immersion of the coatings in an aqueous environment such as blood. Possible implications of this work regarding the development of improved/safer CVCs are briefly discussed.

De verschillende aspecten van recidiverende urineweginfecties bij oudere mannen en vrouwen worden besproken, te weten epidemiologie, pathogenese, symptomatologie, therapie en profylaxe. Waar relevant wordt een vergelijking gemaakt met recidiverende urineweginfecties bij de jongere patient.

Item does not contain fulltext OBJECTIVES: We evaluated the changes in antibiotic resistance from 1998 to 2009 of Klebsiella pneumoniae isolated from the intensive care units (ICUs) and urology services of 14 Dutch hospitals and the consequences for empirical therapy. METHODS: Quantitative antibiotic susceptibility testing of K. pneumoniae was performed in a central laboratory using a microbroth dilution method. Breakpoints were as defined by the European Committee on Antimicrobial Susceptibility Testing (EUCAST). The prevalence of extended-spectrum beta-lactamase (ESBL)- and carbapenemase-producing isolates was determined. RESULTS: A significant increase in resistance among ICU isolates was observed for ceftazidime (4.2%-10.8%), ciprofloxacin (5.8%-18.5%) and trimethoprim/sulfamethoxazole (11.9%-23.1%), and for cefuroxime (2.8%-7.9%) and trimethoprim/sulfamethoxazole (13.5%-27.8%) among urology isolates. Among ICU isolates the prevalence of ESBLs increased significantly from 2% to 8%. Carbapenemase production was not demonstrated. Among ICU isolates the prevalence of multidrug resistance increased and has been >/=12% since 2004. Among urology isolates multidrug resistance was highest in 2009 at 7.4%. Overall, resistance was significantly higher among ICU isolates. CONCLUSIONS: We observed an increase in resistance among ICU and urology isolates and an increased prevalence of ESBLs among ICU isolates. Carbapenemase production was not demonstrated. A regular update of empirical treatment protocols based on actual surveillance data is justified. 01 april 2011

BACKGROUND: The increasing prevalence of uropathogens resistant to antimicrobial agents has stimulated interest in cranberries to prevent recurrent urinary tract infections (UTIs). METHODS: In a double-blind, double-dummy noninferiority trial, 221 premenopausal women with recurrent UTIs were randomized to 12-month prophylaxis use of trimethoprim-sulfamethoxazole (TMP-SMX), 480 mg once daily, or cranberry capsules, 500 mg twice daily. Primary end points were the mean number of symptomatic UTIs over 12 months, the proportion of patients with at least 1 symptomatic UTI, the median time to first UTI, and development of antibiotic resistance in indigenous Escherichia coli. RESULTS: After 12 months, the mean number of patients with at least 1 symptomatic UTI was higher in the cranberry than in the TMP-SMX group (4.0 vs 1.8; P = .02), and the proportion of patients with at least 1 symptomatic UTI was higher in the cranberry than in the TMP-SMX group (78.2% vs 71.1%). Median time to the first symptomatic UTI was 4 months for the cranberry and 8 months for the TMP-SMX group. After 1 month, in the cranberry group, 23.7% of fecal and 28.1% of asymptomatic bacteriuria E coli isolates were TMP-SMX resistant, whereas in the TMP-SMX group, 86.3% of fecal and 90.5% of asymptomatic bacteriuria E coli isolates were TMP-SMX resistant. Similarly, we found increased resistance rates for trimethoprim, amoxicillin, and ciprofloxacin in these E coli isolates after 1 month in the TMP-SMX group. After discontinuation of TMP-SMX, resistance reached baseline levels after 3 months. Antibiotic resistance did not increase in the cranberry group. Cranberries and TMP-SMX were equally well tolerated. CONCLUSION: In premenopausal women, TMP-SMX, 480 mg once daily, is more effective than cranberry capsules, 500 mg twice daily, to prevent recurrent UTIs, at the expense of emerging antibiotic resistance. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN50717094.

Selective decontamination of the digestive tract (SDD) has been shown to decrease the infection rate and mortality in intensive care units (ICUs); Lactobacillus plantarum 299/299v plus fibre (LAB) has been used for infection prevention and does not harbour the potential disadvantages of antibiotics. The objective was to assess whether LAB is not inferior to SDD in infection prevention.Two hundred fifty-four consecutive ICU patients with expected mechanical ventilation a parts per thousand yen48 h and/or expected ICU stay a parts per thousand yen72 h were assigned to receive SDD: four times daily an oral paste (polymyxin E, gentamicin, amphotericin B), enteral solution (same antibiotics), intravenous cefotaxime (first 4 days) or LAB: two times daily L. plantarum 299/299v with rose-hip.The primary endpoint was infection rate. A difference The trial could not demonstrate the non-inferiority of LAB compared with SDD in infection prevention. Results suggest no increased ICU mortality risk in the LAB group.

Background: To optimize empirical treatment of urinary tract infections (UTIs), regular evaluation of the antibiotic susceptibility of the most common uropathogen, Escherichia coli, is necessary. We compared the antibiotic prescription rate for UTIs in women and E. coli antibiotic susceptibility results, including the prevalence of extended-spectrum beta-lactamase (ESBL) producing strains, in 2009 with data collected 5 years ago. Methods: Urinary samples of female patients with symptoms of uncomplicated UTI in 42 general practices, all participating in the Sentinel Stations network of NIVEL, were collected during a 6-month period. Uropathogens were identified and the antibiotic susceptibility of E. coli was determined. Results: We analysed 970 urine cultures, of which 785 (81%) were considered positive (103 cfu/ml). Escherichia coli accounted for 72% of the isolates. ESBLs showed an increase between both surveys (0.1 versus 1%, P < 0.05), while no difference in antibiotic susceptibility of the commonly used antimicrobial agents for UTIs was observed. A significantly lower susceptibility rate to co-amoxiclav was observed in the eastern region compared with the northern part of the country (80 versus 92%, P < 0.05). Consistent with national guidelines, the prescription rate of trimethoprim decreased over time (19 versus 5%, P < 0.05) whereas nitrofurantoin and fosfomycin rates showed an increase (58 versus 66% and 0 versus 5% respectively, both P < 0.05). Conclusions: The antibiotic susceptibility of uropathogenic E. coli did not change over a 5-year period in female patients with uncomplicated UTI in The Netherlands, but ESBL-prevalence increased. With respect to the prescription of antimicrobial agents a good compliance to national UTI guidelines was observed.

The aim of the present study was to investigate the antibiotic susceptibility patterns and molecular epidemiology of clinical methicillin-resistant Staphylococcus aureus (MRSA) isolates recovered in 24 hospitals in 20 cities in Croatia from October to December 2004. A total of 1815 consecutive S. aureus isolates were recovered, 248 of which were MRSA. The MRSA isolates were analysed using spa typing, multilocus sequence typing and SCCmec typing. Furthermore, the presence of Panton-Valentine leukocidin (PVL) genes was determined as a genetic marker for community-associated MRSA. The MRSA prevalence was 14%. Ninety-six per cent of the MRSA isolates were resistant to ciprofloxacin, 95% to clindamycin and azithromycin, 94% to gentamicin, and 93% to erythromycin. The majority of the MRSA isolates (78%) was associated with the ST111-MRSA-I clone. In addition, various other endemic MRSA clones were observed, such as the ST247-MRSA-I (4%), the ST45-MRSA-IV (2%), the ST5-MRSA-I (2%), the ST239-MRSA-III (2%), the ST5-MRSA-II (1%), the ST8-MRSA-IV (1%) and the ST5-MRSA-IV (

For us to assess the spread of methicillin-resistant Staphylococcus aureus (MRSA), typing of the staphylococcal cassette chromosome mec (SCCmec) is a valuable addition to existing typing methods, such as multilocus sequence typing (MLST). Traditional SCCmec typing assays, that is, that of Oliveira et al. and Ito et al., are polymerase chain reaction (PCR) based, requiring electrophoresis. We introduce a rapid, 2-well, multiplex real-time PCR assay that can be used directly on bacterial suspensions and is able to characterize SCCmec type I to V based on the detection of the ccr genes and the mec complex. The assay was evaluated on 212 clinical MRSA isolates from various countries, associated with MLST clonal complexes (CC) 1, 5, 8, 22, 30, and 45, as well as pig-associated CC398. When comparing the real-time PCR assay with traditional methods, the correct SCCmec element was identified in 209 (99%) of the 212 MRSA isolates. The new assay enables high-throughput analyses for SCCmec on large strain collections.

This study investigated the number and type of chronic wounds actually treated by Dutch nursing home physicians (NHPs). It was also the goal to know how many of the treated chronic wounds they considered infected. The NHPs were asked to choose and rank their top five out of several provided criteria for chronic wound infection. After this, the ranking was compared with the choices an international multidisciplinary Delphi group of wound experts made in 2005. A cross-sectional descriptive survey was conducted using the information from a self-reported questionnaire in a representative sample of Dutch NHPs. About 361 NHPs (25%) were sent a questionnaire. Of the 361 physicians, 139 (38.5%) filled in and returned the questionnaire of which 121 were valid. Of the NHPs, 73.5% actually treated at least one chronic pressure ulcers (PU), whereas 26.5% did not treat any. Of the responding NHPs,31.6 % treated at least one, but never more than two chronic post surgical wounds , whereas 68.4% of the NHPs treated none [corrected]. Chronic venous leg ulcers, arterial ulcers and diabetic ulcers scored infrequently and less than the other two sorts of chronic wounds. Of the Dutch NHPs, 53% considered that none of the PU infected. The other chronic wounds were judged far less frequently to be infected. Dutch NHPs appeared to use more 'traditional' criteria such as 'puss/abscess' and 'malodour' to identify infection and did not change their criteria by wound type. According to this study, NHPs do not frequently see many chronic wounds. The most frequent type of wounds treated was PU. For NHPs, the identification of infection of all types of chronic wounds is difficult. The use of criteria that is not in line with consensus documents may lead to ineffective treatment and even seriously damage patients: the clinical identification of infection is still dependent on experts' opinion. Further research on triggers for the suspicion of wound infection and the development of an evidence-based guideline is necessary.

The aim of this study was to investigate the methicillin-resistant Staphylococcus aureus (MRSA) clones isolated in a Dutch university hospital, situated near the borders of Belgium and Germany, between 2002 and 2006. MRSA strains (n = 175) were characterized using spa and SCCmec typing. The presence of Panton Valentine leukocidin (PVL) was determined. Between 2002 and 2005, ST5-MRSA-IV was predominant, and the spa type of ST5-MRSA-IV changed from t002 to t447. ST5-MRSA-I, ST5-MRSA-II, ST228-MRSA-I, and ST247-MRSA-I were also observed in this period. From 2004, the MRSA genetic background became more diverse, and in 2006, ST5-MRSA-IV was only sporadically observed. From 2005, ST5-MRSA-II, ST8-MRSA-IV, ST22-MRSA-IV, and ST45-MRSA-IV were increasingly observed. Several other MRSA clones, such as ST239-MRSA-III, were found sporadically. Four PVL-positive MRSA isolates were observed, associated with ST80-MRSA-IV and ST8-MRSA-IV. ST5-MRSA-I, ST5-MRSA-II, ST5-MRSA-IV, and ST228-MRSA-I have not been described previously in The Netherlands.

Item does not contain fulltext BACKGROUND: The increase in incidence of atopic diseases (ADs) in the developed world over the past decades has been associated with reduced exposure of childhood infections. OBJECTIVE: To investigate the relation between early intestinal viral infections in relation to the development of atopic symptoms (eczema, wheeze and atopic sensitization) in the first and second year(s) of life. METHODS: In the KOALA Birth Cohort Study, we assessed IgG seropositivity for rota- and norovirus (GGI.1 and GGII.4) at 1 year of age. This was related to allergic sensitization [specific immunoglobulin E (IgE)] at 1 and 2 years, and parent reported eczema and wheeze in the first 2 years, using logistic regression analysis adjusted for confounders. RESULTS: Rotavirus seropositivity (39%) was associated with an unexpected higher risk of recurrent wheeze in the first and second year of life [adjusted odds ratio (OR) 3.1 and 95% confidence intervals (CI) 1.1-9.1] and persistent and new recurrent wheeze (adjusted OR 2.7 and 95% CI 1.1-6.2). No further associations were found between intestinal viral seropositivity and atopic manifestations. CONCLUSION: Our data did not show a clear protection by enteric viral infections in young children on development of IgE response to allergens, but rotavirus infection in the first year was a risk factor for wheeze. However, this needs to be followed up to older ages in order to establish the true importance of intestinal viral infections and especially cumulative effects in AD aetiology. Exposure to rotavirus may offer a new and interesting focus on infant wheeze and later asthma development.

PURPOSE: Soluble Triggering Receptor Expressed on Myeloid cells-1 (sTREM-1) has proven to be a good biomarker for sepsis. For the diagnosis ventilator-associated pneumonia (VAP), however, there have only been a few, relatively small, studies on the role of this receptor. The aim of the study was to evaluate the usefulness of sTREM-1 in bronchoalveolar lavage fluid (BALF) from Intensive Care Unit patients as rapid diagnostic test for VAP. METHODS: The concentration of sTREM-1 in 240 BALF samples was measured using a quantitative sandwich enzyme immunoassay. Two researchers who were blind to the assay results determined whether a VAP was present or not. Clinical suspicion of a VAP was confirmed by the presence of > or = 2% cells containing intracellular organisms and/or a quantitative culture result of > or = 10(4) colony forming units per millilitre BALF. RESULTS: The mean concentration of sTREM-1 was significantly higher in the BALF of patients with confirmed VAP than in that of patients without confirmed VAP. However, the area under the receiver-operating characteristic curve was 0.58 (95% confidence interval 0.50-0.65, P = 0.04). CONCLUSIONS: The results imply that the sTREM-1 assay in BALF may not be discriminative for VAP.

To investigate the prevalence, the antibiotic resistance pattern and the population structure of Staphylococcus aureus, S. aureus isolates from the anterior nostrils of patients of general practitioners (GPs) were analysed. Insight into the S. aureus population structure is essential, as nasal carriers of S. aureus are at increased risk of developing an S. aureus infection. S. aureus was isolated from nasal swabs from 2691 patients with no sign of an infection collected in 29 GP practices in The Netherlands. The susceptibility pattern for several classes of antibiotics was determined, as well as the S. aureus genetic background, using spa typing. S. aureus was isolated from 617 of the 2691 (23%) nasal swabs. The prevalences of resistance to ciprofloxacin, co-trimoxazole, fusidic acid, macrolides and mupirocin were 0.2%, 0%, 6%, 5% and 1%, respectively. Half of the isolates were associated with a genetic background common to the major methicillin-resistant S. aureus (MRSA) clones, e.g. clonal complex (CC)1, CC5, CC8, CC22, CC30 and CC45, and the remainder were mainly associated with CC7, CC12, CC15, CC26, CC51 and CC101. The low prevalences of resistance suggest that, in the Dutch situation, S. aureus isolates from patients visiting their GP because of complaints not related to infection do not represent a large reservoir of antibiotic resistance genes. Although no MRSA isolates were found, the genetic background of some of the S. aureus isolates is commonly observed among community-associated (CA)-MRSA clones (CC1, CC8 and CC30), and this might suggest that these isolates have the potential to become CA-MRSA.

A broad variety of infections, ranging from minor infections of the skin to post-operative wound infections can be caused by Staphylococcus aureus. The adaptive power of S. aureus to antibiotics leaded, in the early 1960s, to the emergence of methicillin-resistant S. aureus (MRSA). The cause of resistance to methicillin and all other beta-lactam antibiotics is the mecA gene, which is situated on a mobile genetic element, the staphylococcal cassette chromosome mec (SCCmec). Seven major variants of SCCmec, type I to VII, are distinguished. The most important techniques used to investigate the molecular epidemiology of S. aureus are pulsed-field gel electrophoresis (PFGE), multilocus sequence typing (MLST), S. aureus protein A (spa) typing and SCCmec typing (only for MRSA). These techniques have been used to study the evolution of the MRSA clones that have emerged since the early 1960s, and to study their subsequent worldwide dissemination. The early MRSA clones were hospital-associated (HA-MRSA). However, from the late 1990s, community-associated MRSA (CA-MRSA) clones emerged worldwide. CA-MRSA harbors SCCmec type IV, V or VII, the majority belong to other S. aureus lineages compared to HA-MRSA, and CA-MRSA is often associated with the presence of the toxin Panton-Valentine leukocidin (PVL). However, during recent years, the distinction between HA-MRSA and CA-MRSA has started to disappear, and CA-MRSA is now endemic in many US hospitals. MRSA probably originated trough the transfer of SCCmec into a limited number of methicillin-sensitive S. aureus (MSSA) lineages. This review describes the latest observations about the structure of SCCmec, the techniques used to study the molecular epidemiology and evolution of S. aureus as well as some challenges that researchers face in the future.

An increase in antibiotic resistance of Escherichia coli, the most common pathogen in urinary tract infections (UTIs), is encountered worldwide. Optimal treatment of UTIs will contribute substantially to limit antibiotic use and antimicrobial resistance. This study determined trends in antimicrobial resistance of uropathogenic E. coli, which can be of use to optimize UTI guidelines.During 1998-2005, E. coli from urine samples of patients attending urology services were collected in three regions in The Netherlands: north-east (NE, n = 1084), west (W, n = 1064) and south (S, n = 1212). The antibiotic susceptibility was determined using microbroth dilution following CLSI guidelines. E. coli ATCC 35218 and ATCC 25922 were used as reference strains.Amoxicillin resistance remained stable over time (37% to 47%), but was higher in the south (44%) compared with the other regions (40%; P0.02). Resistance to piperacillin increased from 4% (1998) to 32% (2005; P0.001), and resistance to fluoroquinolones increased from 6% to 13% (P0.01). Interregional differences were observed for resistance to piperacillin (NE 10%, W 12%, S 14%; P0.05) and to fluoroquinolones (NE 7%, W 13%, S 8%; P0.001). Trimethoprim +/- sulfamethoxazole resistance remained stable (27% to 37%), as did that of nitrofurantoin (4% to 9%). The percentage of strains with multidrug resistance (resistance to three or more groups of antibiotics) for each region increased over time (P0.05).Antibiotic resistance was fairly constant over time for most agents tested, except for piperacillin and the fluoroquinolones. Regional differences were observed for several compounds. National and regional surveillance of antibiotic resistance is important to keep therapeutic guidelines up-to-date and adequate for the treatment of resistant microorganisms.

We observed that, between 1999 and 2006, up to 50% of the methicillin-susceptible Staphylococcus aureus (MSSA) bloodstream isolates in our hospital had a genetic background common to endemic methicillin-resistant S. aureus clones (clonal complex 5 [CC5], CC8, CC22, CC30, and CC45). Furthermore, several successful MSSA lineages, such as CC7 and CC15, were observed.

Costs related to a search and destroy policy and treatment for Staphylococcus aureus bacteraemia in the University Hospital Maastricht were calculated for the period 2000 and 2004. The financial cost-benefit break-even point of the search and destroy policy was determined by modelling. On average 22,412 patients were admitted per year for an average of 8.7 days. Each year 246 patients were screened for meticillin-resistant Staphylococcus aureus (MRSA) and 74 patients were decolonised and nursed in preventive isolation. The prevalence of MRSA in the University Hospital Maastricht was 0.7%, as calculated from positive blood cultures, and mean length of stay for all patients with S. aureus bloodstream infections was 39.9 days. The annual cost of pro-active searching for MRSA in the University Hospital Maastricht was euro 1,383,200, and euro 2,736,762 for MRSA prevention and treatment of S. aureus bloodstream infections. Simulation of a variety MRSA/meticillin-susceptible S. aureus (MSSA) ratios showed that even if the MRSA prevalence reaches 8%, prevention costs are still lower than the cost of treating S. aureus infections. In conclusion, the total cost of a search and destroy policy is lower than the cost of treating S. aureus bloodstream infections in the University Hospital Maastricht. At an MRSA prevalence of

The prevalence and degree of antibiotic resistance in catfish and eel farms in the southern part of The Netherlands was examined using motile aeromonads as indicator bacteria. A total of 29 water samples were collected, originating from six catfish farms, one catfish hatchery and three eel farms, and were plated on an Aeromonas-selective agar with and without antibiotics. From each plate, one colony was screened for presumptive motile aeromonads and tested for antibiotic susceptibility. The prevalence of resistance was as follows: ampicillin and oxytetracycline 100%; sulfamethoxazole 24%; trimethoprim 3%; and ciprofloxacin and chloramphenicol 0%. The majority of samples showed a high degree of oxytetracycline resistance, implicating fish farms as a major reservoir of oxytetracycline resistance genes. This reservoir might form a risk for human health and has major consequences for the effectiveness of this antibiotic in the treatment of infectious diseases in fish.

The prevalence of atopic diseases, including eczema, allergic rhinoconjunctivitis and asthma, has increased worldwide, predominantly in westernized countries. Recent epidemiological studies and experimental research suggest that microbial stimulation of the immune system influences the development of tolerance to innocuous allergens. The gastrointestinal microbiota composition may be of particular interest, as it provides an early and major source of immune stimulation and seems to be a prerequisite for the development of oral tolerance. In this review the observational studies of the association between the gut microbiota and atopic diseases are discussed. Although most studies indicated an association between the gut microbiota composition and atopic sensitization or symptoms, no specific harmful or protective microbes can be identified yet. Some important methodological issues that have to be considered are the microbiological methods used (traditional culture vs molecular techniques), the timing of examining the gut microbiota, the definition of atopic outcomes, confounding and reverse causation. In conclusion, the microbiota hypothesis in atopic diseases is promising and deserves further attention. To gain more insight into the role of the gut microbiota in the etiology of atopy, large-scale prospective birth cohort studies using molecular methods to study the gut microbiota are needed.

Ventilator-associated pneumonia (VAP) is a nosocomial infection occurring in the intensive care unit (ICU). The diagnostic standard is based on clinical criteria and bronchoalveolar lavage (BAL). Exhaled breath analysis is a promising non-invasive method for rapid diagnosis of diseases and contains volatile organic compounds (VOCs) that can differentiate diseased from healthy individuals. The aim of this study was to determine whether analysis of VOCs in exhaled breath can be used as a non-invasive monitoring tool for VAP. One hundred critically ill patients with clinical suspicion of VAP underwent BAL. Before BAL, exhaled air samples were collected and analysed by gas chromatography time-of-flight mass spectrometry (GC-tof-MS). The clinical suspicion of VAP was confirmed by BAL diagnostic criteria in 32 patients [VAP(+)] and rejected in 68 patients [VAP(−)]. Multivariate statistical comparison of VOC profiles between VAP(+) and VAP(−) revealed a subset of 12 VOCs that correctly discriminated between those two patient groups with a sensitivity and specificity of 75.8% ± 13.5% and 73.0% ± 11.8%, respectively. These results suggest that detection of VAP in ICU patients is possible by examining exhaled breath, enabling a simple, safe and non-invasive approach that could diminish diagnostic burden of VAP.

Ventilator-associated pneumonia (VAP) is a hospital-acquired infection occurring in the intensive care unit (ICU). The current diagnostic standard is bronchoalveolar lavage (BAL). However, this method is invasive and time-consuming. Analysis of volatile organic compounds (VOCs) in exhaled breath is a non-invasive method that is able to diagnose many pulmonary diseases including COPD and asthma. The aim of this study was to assess the diagnostic potential of exhaled breath to diagnose VAP in ventilated critically ill patients in the ICU. A total of 100 ventilated critically ill patients who were clinically suspected of VAP were included. Using BAL microbial analysis, the clinical suspicion of VAP was confirmed in 32 patients (VAP+) and rejected in 68 patients (VAP-). Prior to the BAL procedure, an exhaled air sample was collected from each patient. The exhaled air samples were measured for the total amount of VOCs by gas chromatography – time of flight – mass spectrometry (GC- tof -MS), and subsequently analysed by multivariate statistics to extract the compounds with the most discriminative power. Statistical comparison revealed that 12 VOCs could correctly classify VAP+ and VAP- with an accuracy of 74.2% ± 4.3 and a sensitivity and specificity of 75.8% ± 5 and 73.0% ± 4.3 respectively. These results suggest that it is possible to determine the presence of VAP in ICU patients by exhaled breath. Such a quick and non-invasive diagnosis of VAP will reduce the disease burden of these patients by earlier diagnosis, but will also reduce the necessity for BAL in the ICU.

Inadequate therapy in bloodstream infections is suggested to be associated with higher mortality. We evaluated the reduction in inappropriate antibiotic therapy using rapid identification and antibiotic susceptibility testing (FAST) compared to standard of care (SOC) testing in patients with bloodstream infections. The FAST method used polymerase chain reaction (PCR) for identification and to detect growth in the presence or absence of antibiotics after only 6 h. For SOC testing, the BD Phoenix system was used. Patients with blood cultures growing Staphylococcus, Streptococcus or Enterococcus species or Gram-negative rods were randomised for FAST or SOC tests. A total of 129 patients were randomised for FAST and 121 patients for the SOC group. At the time SOC results became available, 78 patients in the FAST group could have been switched to more appropriate therapy. Although FAST results were highly accurate (agreement with SOC was 94 %), they were only implemented in a minority (16) of patients. However, significantly fewer patients in the FAST group used inappropriate therapy at the time of SOC results (p = 0.025). The time to results in the FAST group was reduced by 15.6 h (p < 0.001). In the patients switched after FAST, this was done after a mean of 42.3 h compared to 61.4 h in those switched after SOC tests (p < 0.001). In bacteraemic patients, FAST resulted in significantly more patients using appropriate antibiotic therapy at the time SOC results were available and 15.6 h earlier than SOC tests. However, the implementation of FAST results was not optimal and no benefit on clinical outcome was shown.