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In three hospitals three women aged 34, 33 and 25 years respectively, developed fever following delivery; in two of them a beta-haemolytic streptococcus of Lancefield group A (GAS) was cultured. Between the time of transmission of the infective agent of the first and the third patients there was a period of ten days. Because the intervals between the emergence of cases were relatively long, the suspicion of a common vector, i.e. the midwife, was raised only after some time. The midwife who had been present at all three deliveries turned out to be negative for GAS carriership on three occasions. However, cultures taken from her son and partner were positive for GAS carriership. A number of typing systems were unable to distinguish the GAS-isolates from the first two patients and from the son. After the midwife and her family members had been treated, no new cases occurred. This case illustrates the importance of keeping midwives as well as the department of public health informed of a rise in the number of cases of puerperal fever, whether the cases involve more than one hospital or not, in order to prevent a potential epidemic. Only then can a common source be looked for and the epidemic contained.

After a steady decrease in morbidity and mortality resulting from severe group A streptococcal (GAS) infections, the 1980s witnessed a resurgence of invasive GAS disease. As a result a nationwide laboratory-based surveillance for invasive GAS infections was conducted at the National Institute of Public Health (RIVM) from 1994 to 2003. The estimated annual incidence ranged from 2.0 to 4.0 cases per 100,000 individuals per year. The case-fatality rate was 18% overall but varied substantially depending on the manifestation of the disease. GAS infections may be complicated by toxic shock-like syndrome (TSS) which is caused by bacterial exotoxins. Case fatality among TSS cases was 59%. The M-protein that extends from the cell membrane is used for sub-typing GAS in > 150 different M-types. Increased intrinsic virulence has been reported in Streptococcus pyogenes of certain M-types, notably M1 and M3. In the Netherlands these M-types have been independently associated with fatality. Over the last 50 years the genome of these M-types appears to have become enriched with phage-encoded virulence factors, possibly contributing to the altered epidemiology of invasive GAS disease. Despite this genetic plasticity, GAS have remained uniformly susceptible to penicillin. In-vitro studies have shown that the administration of immunoglobulin G can have a neutralising effect in cases ofTSS but clinical studies have failed to provide any statistical support for this.

Enterococci (Enterococcus faecalis and Enterococcus faecium) are relatively avirulent enteric bacteria that usually only cause infections in immunocompromised patients. Antimicrobial treatment, however, is hampered as enterococci are intrinsically resistant to many antibiotics. For years, vancomycin was considered the last available antibiotic. Plasmid-mediated resistance against vancomycin among enterococci was first described in the nineteen-eighties and since then incidences of infection caused by vancomycin-resistant enterococci (VRE) have increased dramatically, especially in the United States. In 2000, three outbreaks of VRE occurred in hospitals in the Netherlands and a set of infection-control measures was proposed to limit further transmission. These measures were based on the simultaneous isolation of VRE from multiple patients. All three outbreaks were controlled by these measures and no new outbreaks in Dutch hospitals have been reported since then. Epidemiological studies have shown that hospital outbreaks on three continents were caused by a subpopulation of E. faecium, which is characterized by the presence of a potential virulence gene (variant esp) and resistance to amoxicillin. This 'hospital strain' of E. faecium has probably been prevalent within hospital settings for some time, but only became clinically relevant when it had acquired vancomycin-resistance. Current advice is to implement the set of infection control measures formulated in 2000, only in those patients colonized by amoxicillin-resistant VRE. The potential dangers of VRE were recently underlined by the proven transmission of the vancomycin-resistance gene from VRE to methicillin-resistant Staphylococcus aureus (MRSA) in two patients in the United States. It is in the interest of the patients that prevalence of VRE and MRSA in Dutch hospitals should be kept as low as possible.

Within a four-week period, five patients were admitted to the maternity ward of the Utrecht Children's Hospital diagnosed with puerperal sepsis due to group-A streptococcal infection. The clinical presentation was different for each patient. All patients recovered upon adequate antibiotic treatment. One of the children died, possibly due to sepsis and hypotension of his mother. As group-A streptococci can be extremely contagious and an epidemic was suspected, measures for additional hygiene were taken. Furthermore, all personnel at the maternity ward and the obstetric centre were tested. T-serotyping, M-genotyping, exotoxin A- and C-gene amplification and pulsed field gel electrophoresis were used to characterize the cultured group-A streptococci. Cross-contamination was not found. Therefore, this increase in puerperal sepsis was attributed to polyclonal expansion rather than an epidemic. All mothers of newly born children who present with fever and lower abdominal pain should be suspected of group-A streptococcal infection. Evaluation and treatment in hospital is indicated due to a sometimes fulminant course. When group-A streptococci are cultured again in a new pregnancy, eradication therapy during pregnancy or prophylactic treatment during birth should be considered to prevent recurrent infection.

Two burns patients who were transferred to the Central Military Hospital Utrecht from a foreign hospital, were found to be colonised with MRSA. During their 5-week hospitalisation, 21 healthcare workers and one patient became colonised with the same MRSA strain, despite isolation precautions. The department was closed for 29 days; 96 admissions were cancelled and 1411 screening cultures for MRSA were performed. Colonised healthcare workers were temporarily unable to work and additional costs were incurred for disposables and cleaning procedures. The resultant bill for this outbreak was approximately [symbol: see text] 122,500. MRSA outbreaks occur in hospitals with some degree of regularity, but the strong dispersal during this epidemic was exceptional. The transfer of possible MRSA-colonised patients from hospitals outside of the Netherlands sometimes faces opposition due to the considerable demands it makes on a hospital's personnel, organisation and finances. If this were to be compensated, then the currently successful Dutch MRSA policy could be coupled with a willingness to accept patients from hospitals outside of the Netherlands.

Recently, three epidemics in Dutch hospitals were caused by vancomycin-resistant enterococci (VRE). Although the number of infections was small, spread of colonization was extensive and many infection control measures were necessary to prevent further spread. VRE are relatively avirulent bacteria. However, few, if any, antibiotics are available for treatment of infections caused by VRE and the genetic code for resistance may be transferable to other, more virulent, bacteria, such as methicillin-resistant Staphylococcus aureus (MRSA). Although colonization and infection with MRSA have become endemic in many surrounding countries, such a situation has been prevented in the Netherlands by employing an aggressive 'search and destroy' policy. Although many questions regarding the optimal approach of VRE remain unanswered, a similar policy as employed for MRSA will not be possible. In contrast to MRSA, colonization with VRE occurs in the open population, no populations with increased risk for colonization appear to be definable and colonization cannot be eradicated. Based on common sense, a differentiated approach seems indicated in which extensive infection control measures should only be implemented when spread of a single genotype has been demonstrated. A reference laboratory should be created for uniform genotyping.

After a report of a possible relationship between an outbreak of vancomycin-resistant enterococci (VRE) in a nearby hospital and earlier admission of two of the patients with this VRE in the University Medical Centre of Utrecht (UMCU), the Netherlands, an extensive search for VRE carriers was started in the UMCU. In the study period of two months, VRE carriership was diagnosed in 51 patients in nine of the 11 wards investigated. Twenty-six patients in eight wards were colonized with the same VRE genotype as in the nearby hospital; spread was demonstrated in three wards. In addition, six patients of one ward were colonized with a second genotype and seven other patients with a third genotype, while 12 patients were carriers of a unique genotype. Most carriers were found in the internal medicine/nephrology and dialysis ward. Far-reaching measures (such as cohort nursing, admission stops, use of gowns and gloves, disinfection and restriction of use of vancomycin) taken in the four wards where spread was demonstrated, appeared effective but in three wards, spread was again demonstrated later. Frequent readmissions and transfers of patients appear to play an important part in this matter. None of the 51 colonized patients developed a serious VRE infection.