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In addition to acute care hospitals, rehabilitation centres are increasingly confronted with multi-resistant pathogens. Long durations of stay and intensive treatments impose special hygienic challenges.We investigated an extended spectrum beta-lactamase-Klebsiella pneumoniae (ESBL-K. pneumoniae) outbreak in a neurorehabilitation centre. We defined confirmed cases as patients who stayed in the centre during the outbreak period and from whom ESBL-K. pneumoniae was isolated with the outbreak sequence type. Probable cases had an epidemiological link to at least one confirmed case but no isolate for typing. Next generation sequencing (NGS) was performed on 53 isolates from patients. Environmental sampling was performed. Systematic microbiological screening was implemented and ESBL-K. pneumoniae-positive patients were cohorted in a designated ward.We identified 30 confirmed and 6 probable cases. NGS revealed three genetic clusters: Cluster 1 - the outbreak cluster - with isolates of 30 cases (sequence type ST15), Cluster 2 with 7 patients (ST405) and Cluster 3 with 8 patients (ST414). In two patients, the outbreak strain developed further antibiotic resistance, one with colistin resistance and the other carbapenem resistance. The outbreak ceased after strict isolation measures.Epidemiology and NGS results paired with the effectiveness of cohorting suggest that transmission occurred mainly from person to person in this outbreak. There was an apparent association of the probability to acquire ESBL-K. pneumoniae and treatment intensity, whereas infection rate was related to morbidity. The identification of the outbreak clone and additional clusters plus the development of additional antibiotic resistance shows the relevance of NGS and highlights the need for timely and efficient outbreak management.

Infektionen mit extended-spectrum Betalaktamase-produzierenden Enterobacteriaceae (ESBL-E) sind assoziiert mit einer erhöhten Mortalität. Die Unterschiede im klinischen Bild, die den verschiedenen Spezies der ESBL-E oder ESBL-Genotypen geschuldet sind, wurden noch nicht ausreichend untersucht. Wir führten eine Kohortenstudie zur Bewertung der Risikofaktoren für Sterblichkeit in Fällen mit einer ESBL-E-Bakteriämie (K. pneumoniae oder E. coli) und zur Bewertung der Risikofaktoren für Sepsis mit Organversagen durch. Eingeschlossen wurden alle Patienten unserer Institution mit einer ESBL-E-Bakteriämie in der Zeit von 2008 bis 2011. Epidemiologische Basisdaten, zugrundeliegende Komorbiditäten, Ursprung der Bakteriämie, Schweregrad der Sepsis und Daten zur zeitlichen Verzögerung bis zu Beginn der adäquaten antibiotischen Therapie wurden gesammelt. Die Isolate wurden mittels PCR auf das Vorhandensein von ESBL-Genen und plasmidvermittelten AmpC β-Laktamasen untersucht. Wir führten eine Cox Regressionsanalyse zur Mortalität und eine multivariable logische Regression zu den Risikofaktoren für eine Sepsis mit Organversagen durch. Insgesamt wurden 219 Fälle in die Analyse eingeschlossen: 71,3% mit E. coli, 26,9% mit K. pneumoniae. Wir fanden keine signifikanten Unterschiede bei der Krankenhaussterblichkeit (ESBL-E. coli 23.8% vs. ESBL-K. pneumoniae 27.1%, p=0.724). Bakteriämien mit K. pneumoniae (OR 4.5, p, Infections with extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) are associated with increased mortality. Outcome differences due to various species of ESBL-E or ESBL genotypes are not well investigated. We conducted a cohort study to assess risk factors for mortality in cases of ESBL-E bacteremia (K. pneumoniae or E. coli) and the risk factors for sepsis with organ failure. All consecutive patients of our institution from 2008 to 2011 with bacteremia due to ESBL-E were included. Basic epidemiological data, underlying comorbidities, origin of bacteremia, severity of sepsis and delay of appropriate anti-infective treatment were collected. Isolates were PCR- screened for the presence of ESBL genes and plasmid-mediated AmpC β-lactamases. Cox proportional hazard regression on mortality and multivariable logistic regression on risk factors for sepsis with organ failure was conducted. 219 cases were included in the analysis: 73.1% due to E. coli, 26.9% due to K. pneumoniae. There was no significant difference in hospital mortality (ESBL-E. coli, 23.8% vs. ESBL-K. pneumoniae 27.1%, p=0.724). However, the risk of sepsis with organ failure was associated in cases of K. pneumoniae bacteremia (OR 4.5, p

Die Inzidenz von Infektionen mit Extended- Spectrum- Beta- Lactamase (ESBL) bilden-den Enterobacteriaceae steigt seit einigen Jahren in Deutschland stark an. Folgen die-ser Entwicklung sind erhöhte Letalität und Morbidität der betroffenen Patienten. Aber auch kostenintensive und verlängerte Krankenhausaufenthalte und kostenintensive Präventionsmaßnahmen sind Nachwirkungen dieser Entwicklung. Insbesondere in Bezug auf einen der häufigsten ESBL-Bildner, Klebsiella pneumoniae (K. pneumoniae), sind viele Fragen noch unbeantwortet. Wie hoch ist die Letalität bei Infektionen mit diesen Erregern, welche Resistenzgene sind am weitesten verbreitet und welche Zusatzkosten entstehen durch Infektionen mit diesen Erregern? Wir führten eine Kohortenstudie durch und analysierten Daten von Patienten, die in den Jahren 2008 bis 2011 in der Charité – Universitätsmedizin Berlin behandelt wurden. Es wurden alle Patienten eingeschlossen, die mit einer Bakteriämie durch Escherichia coli (E. coli) oder K. pneumoniae diagnostiziert wurden. Innerhalb dieser Kohorte wurden Bakteriämien mit ESBL-bildenden Erregern mit Bakteriämien durch nicht resistente (sensible) Erreger verglichen. Analysiert wurde außerdem die Verteilung der verschiedenen ESBL-Genotypen innerhalb der Bakteriämie verursachenden K. pneumoniae. Insbesondere wurde der Einfluss von ESBL-Bildung, Alter, Geschlecht, Verweildauer vor und nach Bakteriämie, verschiedener Grunderkrankungen, nosokomialer Bakteriämie und ESBL-Genotyp auf das Letalitätsrisiko einer K. pneumoniae Bakteriämie untersucht. In einer weiteren Analyse wurden obengenannte Parameter und deren Auswirkungen auf Krankenhauskosten und Verweildauer inklusive des Vergleichs zu E. coli Bakteriämien geschätzt. Der Nachweis der ESBL-Gene erfolgte mittels Polymerase-Kettenreaktion (PCR) und Sequenzierung. Die Risikofaktoren für Letalität wie Alter, Geschlecht und Grunderkrankungen wurden mittels multivariabler Regressionsanalyse von Überlebenszeiten nach Cox berechnet. Die Einflussfaktoren auf Krankenhauskosten wurden mittels univariater Analyse, die Daten zu Krankenhausverweildauer mittels multivariabler linearer Regression bewertet. Insgesamt wurden 352 Bakteriämien mit K. pneumoniae eingeschlossen, darunter fan-den sich 19% (n=66) durch ESBL-positive K. pneumoniae. Es konnte kein signifikanter Unterschied hinsichtlich der Letalität von Bakteriämien durch ESBL-positive vs. –negative K. pneumoniae demonstriert werden (25% vs. 24%, p=0,875). Statistisch signi-fikante Risikofaktoren für ein Versterben im Krankenhaus nach K. pneumoniae Bakte-riämie waren chronische Lungenerkrankungen (HR 1,75) und mäßige bis schwere Nierenerkrankungen (HR 2,57). Die häufigsten ESBL-Genotypen waren CTX- M-15 (61%), SHV-5 (27%) und CTX-M-3 (4%). Bakteriämien mit ESBL-bildenden K. pneumoniae waren mit einer verlängerten Verweildauer (vor und nach Infektionsbeginn) assoziiert, im Vergleich zu E. coli und im Vergleich zu ESBL-negativen K. pneumoniae. Nicht nur die Bildung von Resistenzfaktoren wie ESBL, sondern auch die Spezies der Erreger beeinflussen den Krankheitsverlauf und die krankheitsbedingte Verweildauer im Krankenhaus. Infektionspräventionsmaßnahmen sollten in Zukunft auch den Unterschieden der Erregerspezies innerhalb der Familie der Enterobacteriaceae Rechnung tragen., The incidence of infections with Extended-Spectrum Beta-Lactamase (ESBL) –positive pathogens has been increasing for several years in Germany. Consequences of this development are enhanced morbidity and mortality for affected patients. However, cost-ly and prolonged hospital stays and cost- intensive prevention measures are also reper-cussions of this development. Many questions particularly with regard to one of the most common ESBL- producer, Klebsiella pneumoniae (K. pneumoniae), are still unan-swered: What is the associated mortality-rate of infections with these particular patho- gens? Which resistance genes are responsible for this epidemic? What are the excess costs caused by these infections? We performed a cohort study and analyzed data from patients who were treated in the years 2008 to 2011 in the Charité- Universitätsmedizin Berlin. All patients that were di-agnosed with bacteremia caused by K. pneumoniae or Escherichia coli (E. coli) were included in the analysis. Within this cohort cases with bacteremia due to ESBL- producing E. coli or K. pneumoniae were compared with cases with non-resistant (sus-ceptible) strains of these two species. Various epidemiological and clinical factors were analyzed in order to estimate their effect on hospital mortality and potential excess hos-pital costs respectively. Furthermore, the distribution of different ESBL genotypes was assessed. The detection of ESBL genes was carried out by polymerase chain reaction (PCR) and sequencing. The risk factors for mortality such as age, sex and underlying comorbidities were analyzed using univariate analysis and multivariable Cox regression. The factors on hospital stay were evaluated by univariate analysis and multivariable linear regression. Altogether 352 cases of K. pneumoniae bacteremia were included among which 19% (n=66) were found ESBL-positive. There was no significant difference in regards to mortality between ESBL- positive vs. –negative K. pneumoniae cases (25% vs. 24%, p=0,875). Independent risk factors for in-hospital death after K. pneumoniae bacteremia were lung disease (HR 1.747) and renal disease (HR 2.572). The most common geno-types were CTX ESBL-M-15 (60%), SHV-5 (27%) and CTX-M-3 (5%). Episodes with bacteremia with ESBL-producing K. pneumoniae were associated with a prolonged length of hospital stay (before and after onset of infection) compared to E. coli and ESBL-negative K. pneumoniae cases respectively. Not only the formation of resistance factors as ESBL, but also the infection causing pathogen species has an effect on the length of hospital stay. In the future, in terms of infection prevention measures, ESBL-positive K. pneumoniae should considered differently compared to E. coli in order to effectively prevent transmissions and nosocomial infections.

In terms of the unique risk profile, the clinical course of nosocomial infections, and the most prevalent bacterial pathogens, literature on outbreaks of potentially pathogenic bacteria on neonatal intensive care units (NICUs) needs to be analyzed separately from reports derived from other intensive care units. With the purpose of updating important information for those involved in outbreak management and fostering preventive efforts, this article summarizes the results of a systematic literature analysis, referring to an earlier publication by Gastmeier et al. This review focuses on NICU outbreaks caused by Serratia marcescens, Klebsiella pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa.

We present the case of a 48-year-old Vietnamese man with endophthalmitis, liver abscess, and pulmonary and cerebral septic emboli. Klebsiella pneumoniae was isolated as the causative organism; there were no laboratory findings suggestive of invasive fungal infection. Klebsiella pneumoniae invasive syndrome is a rare disease in Germany. This case report exemplifies the necessity of a dedicated diagnostic approach that takes into consideration factors such as ethnic origin and accompanying diseases of the patient.

The presence of pathogenic bacteria with acquired carbapenem resistance constitutes an increasing problem for infection control and infectious disease management. Prompted by an outbreak of infections with Klebsiella pneumoniae producing the carbapenemase KPC-2 at a hospital in Saxony, the Saxon State Ministry of Social Affairs and Consumer Protection (SMS) initiated a point-prevalence survey for carbapenemase-producing gram-negative bacteria. Wards at 53 hospitals in Saxony, mainly intensive care units, were investigated between October 2012 and February 2013. Stool samples and rectal swabs of 1,037 patients were analyzed for the presence of bacteria with resistance against four major groups of antibiotics (4MRGN). Carbapenemase producers were detected in 3 patients [0.3% CI95 (0.0596; 0.843)] and carbapenem-resistant bacteria without carbapenemases were detected in 9 patients [0.9% CI95 (0.397; 1.64)]. Furthermore, antimicrobial susceptibility testing revealed 166 patients [16.0% CI95 (13.82; 18.38)] with extended-spectrum beta-lactamase (ESBL)-producing bacteria. At the time of investigation, K. pneumoniae producing the carbapenemase KPC-2 was diagnosed in 2 patients at one hospital. Moreover, it is necessary to remain vigilant towards other types of carbapenemase producers, as demonstrated by the finding of a Pseudomonas aeruginosa strain harbouring the carbapenemase VIM-1 in another hospital.

In recent years the resistance of Gram-negative pathogens to beta-lactam antibiotics, such as cephalosporins and carbapenems has increased. The resistant strains produce different beta-lactam hydrolysing enzymes (beta-lactamases). In particular extended spectrum beta-lactamases (ESBL) are prevalent in Escherichia coli and Klebsiella pneumoniae. The ESBL genes are located on different plasmids facilitating the transfer of resistance within a species and between different Gram-negative species. Within the scope of various studies the Robert Koch Institute in Wernigerode investigated ESBL-producing human Enterobacteriaceae using molecular methods. The results showed that distinct ESBL types, such as the CTX-M enzymes are dominant in Germany whereby CTX-M-15 and CTX-M-1 are the most prevalent variants in E. coli and K. pneumoniae. The aim of ongoing investigations within the RESET network project is to investigate the dissemination pathways of ESBL-producing bacteria in different settings (e.g. in humans, animals and food).

The spread of carbapenemase-producing gram-negative bacteria is one of the major challenges of the present. Since 2009, the National Reference Laboratory for gram-negative nosocomial pathogens has observed the molecular epidemiology of carbapenemases in Germany. In 2011, 1,454 referred bacterial isolates were tested for the presence of carbapenemases. Carbapenemase was found in 34.4% of Enterobacteriaceae isolates, in 19.9% of Pseudomonas aeruginosa isolates and in 96.3% of Acinetobacter baumannii isolates. The most frequent carbapenemases in Enterobacteriaceae were OXA-48, KPC and VIM-1; in P. aeruginosa it was VIM-2 and in A. baumannii OXA-23.

In 2007, the Robert Koch Institute established the infrastructure for the national Antimicrobial Resistance Surveillance (ARS) system. Laboratories submit data of routine susceptibility testing of clinical samples from hospitals as well as from outpatient care settings in a standardized format to the Robert Koch Institute for central processing. The database for the period 2008-2011 comprises data of about 1.3 million samples from patients in hospital care and almost 800,000 samples from outpatients. Based on SIR interpretations of susceptibility, the trends of methicillin resistance of Staphylococcus aureus (MRSA) and cefotaxime non-susceptibility as an indicator of extended-spectrum beta-lactamases (ESBL) of Escherichia coli and Klebsiella pneumoniae were analyzed for four care settings or categories: hospital care, outpatient care, intensive care units, and isolates from blood cultures. After constant high levels of above 20%, the proportion of MRSA isolates showed a decline for the first time from 2010 to 2011 in hospital care overall, in intensive care units as well as in blood cultures; in outpatient care, MRSA proportions of about 13% were observed. Within the observed period, non-susceptibility to cefotaxime as an indicator of ESBL in E. coli showed an increasing trend in hospital care at a level above 10% in intensive care units, while cefotaxime non-susceptibility in K. pneumoniae was more frequent but without any trend. In outpatient care, the proportions of cefotaxime non-susceptibility increased year by year in both species resulting in nearly a doubling to 6%.

Multiresistant, extended spectrum beta lactamase (ESBL)-producing pathogens are an increasing problem in daily clinical life. This paper summarizes the development of resistance as well as epidemiology, diagnostics, and treatment of ESBL-producing micro-organisms. We analyzed microbiological data collected at the Grosshadern Clinic in Germany between 1996 and 2007, in order to assess the importance of these micro-organisms to medical practice and surgical care units.Pathogens were isolated from 28,894 patients with Escherichia coli and 10,903 with Klebsiella pneumoniae pathogens between 1996 and 2006 and tested for ESBL production. For the year 2007 we have analyzed the complete spectrum of ESBL-producing pathogens and their distribution to different departments of the clinic. The agar diffusion test with five cephalosporins and an automated detection system (BD Phoenix) were used for screening purposes. Positive results were verified with the E- and double-disc agar diffusion tests.The most important pathogens isolated from patients were E. coli and K. pneumoniae. Analysis of ESBL-producing E. coli pathogens from 1996 to 2006 showed the prevalence increasing from 0% to 4.1%. For ESBL-producing K. pneumoniae, we also found a prevalence rising from 0.3% in 1996 to 6.6% in 2006. For the year 2007 a further increase in ESBL-producing pathogens was detected, reaching 182 cases, with 118 of ESBL-producing E. coli (5.7 %) and 39 of ESBL-producing K. pneumoniae (7.4%). Of these, 24 cases with E. coli and nine with K. pneumoniae were surgery patients (20% and 23%, respectively).The results show an increasing prevalence of ESBL-producing pathogens in hospitalized patients and in surgical departments. The resulting rise in treatment costs and patient risk require thorough knowledge of risk factors, therapy, and preventive measures.

The occurrence of multidrug-resistant microorganisms is associated with an extended and long-term use of broad-spectrum antibiotics. Indeed, this may lead to a colonization and even to an infection of the patient, which is called collateral damage. Moreover, the risk for collateral damage can be assessed for different antibiotic classes. OCCURRENCE OF MULTIDRUG-RESISTANT MICROORGANISMS: The use of cephalosporins may induce a subsequent infection with vancomycin-resistant enterococci, extended-spectrum beta-lactamase-producing Klebsiella pneumoniae, beta-lactam-resistant Acinetobacter species, and Clostridium difficile. Quinolones are associated with a subsequent infection with methicillin-resistant Staphylococcus aureus and with increasing resistance in gram-negative bacilli, such as Pseudomonas aeruginosa.To avoid the occurrence of multidrug-resistant microorganisms, a strict indication and time-limited use (e.g., 1 week) of antibiotics are required, as already established in the guidelines for infection.

A 33-year-old drug addict injected accidentally into the femoral vein 5 ml urine (kept in the refrigerator for 1 week for unanticipated drug-screening) which she mis-took for methadone. Soon after injection she was found confused with shivering. On admission she had a blood pressure of 90/60 mmHg, heart rate of 120/min and fever of 40 degrees C.Laboratory tests showed consumption coagulopathy (DIC) as well as leukopenia. Blood cultures were positive for E.coli and Klebsiella pneumoniae. Infection with hepatitis C and HIV was excluded. Echocardiography revealed good ventricular function without signs of endocarditis.The patient developed a fulminant Gram-negative sepsis with DIC and multi-organ failure. She was intubated and mechanically ventilated. Acute renal failure required haemodialysis and ultrafiltration. Septic shock was treated with fluids and high doses of vasopressors. DIC was effectively treated with tranexamic acid, PPSB complex and fresh frozen plasma. The further course was complicated by septic emboli to the myocardium, liver, kidney and spleen. Laparotomy because of an acute abdomen revealed perforation of terminal ileum (mainly due to ischemic bowel lesions) requiring partial resection. The patient was weaned on day 18 with an initially uneventful further course. On day 25 the patient had a cardiac arrest with at first successful resuscitation but electromechanical dissociation proved fatal on day 26.Although serious systemic inflammation associated with i. v.-injection in drug addicts is rare, one has to be aware of severe complications with septic emboli. To our knowledge it is the first published case of i. v.-injection of urine followed by sepsis and multi-organ failure. Aggressive interdisciplinary treatment is required.

Anomalies of the fetal urachus are rare. Normally, the postnatal urachus presents as a fibrous band extending from the bladder to the umbilicus. Urachal cysts may occur in postnatal life. Spontaneous perforation of urachal cysts is a very rare condition, which clinically may not be distinguishable from other acute abdominal conditions. We report a case of a 63-year-old male with a history of recurrent urinary tract infections and a bladder rupture caused by a spontaneous perforation of an infected urachal cyst. The symptomatology showed abdominal rigidity and pain, a palpable mass in the lower abdomen, and hematuria. Laboratory findings showed leukocytosis and an increased CRP level. The bladder rupture was confirmed by cystography. Bacteriologic examination identified Proteus vulgaris, Corynebacterium species, and Klebsiella pneumoniae. Most of the published cases in the literature report about intraperitoneal perforation of infected urachal cysts. In the present case, we found a spontaneous perforation of an infected urachal cyst leading to an extraperitoneal bladder rupture with an extraperitoneal limitation of the infection. The definitive therapy was complete surgical excision including a cuff of the bladder, drainage, and systemic broad-spectrum and local application of antibiotics. The further course was uneventful.

We report on two cases of multiple hepatic abscesses caused by sever pelvic inflammatory disease secondary to intrauterine device. Such complication have previously been reported only twice. The course of the diseases were non-specifically for a long time. As causative agent we isolated Klebsiella pneumoniae in the first case and in the other Fusobacterium necroforum. The patients were cured with combined operative and medical therapy.

Within 24 hours of returning from a five-week holiday in Pakistan a 15-year-old girl developed vomiting and massive diarrhoea leading to severe dehydration with hypovolaemic shock. The diastolic blood pressure was no longer measurable and prerenal renal failure occurred with a serum creatinine of 4.4 mg/dl and metabolic acidosis (pH 7.21, base excess-16.9 mmol). Initially treatment consisted of rehydration (day 1: 9280 ml, day 2: 4850 ml). The patient's condition rapidly improved and she had voluminous stools. A concurrent urinary infection due to Klebsiella pneumoniae was first treated with cotrimoxazole. As a new strain of Vibrio cholerae, serogroup O 139, was isolated from stool, treatment was changed to tetracycline (50 mg/kg daily). Regaining a good general state she was transferred to an isolation ward on the 6th hospital day. The isolated cholera organism belongs to a nonagglutinating serogroup which is indistinguishable clinically and epidemiologically from the classical Vibrio strains which cause cholera. Since the end of 1992 this new serogroup has been causing an explosive spread of cholera in Bangladesh and India.

A case report on the rare entity of "true" Andrews bacterid and a review of the literature are used to illustrate clinical and morphological criteria that allow discrimination between Andrews bacterid and psoriasis pustulosa palmaris et plantaris. The patient noted the eruption of sterile pustules on palms and soles for the first time in his life at the age of 73 during an attack of acute tonsillitis. He had no history of psoriasis and it was also unknown in the family history. In contrast to psoriasis pustulosa palmaris et plantaris, Andrews bacterid becomes manifest as isolated pustules with an erythematous rim, which do not destroy the ridged skin. On the rest of the integument disseminated pustules are seen but no psoriatic stigmata. Thus, apart from the criterion of coincidence with an infection and the short course, we can also differentiate between Andrews bacterid and psoriasis pustulosa palmaris et plantaris on the basis of clinical criteria.

Spontaneous bacterial peritonitis (SBP) constitute a rare complication of cirrhosis of the liver with a high mortality rate. Unspecific sings of decompensation like increasing elaboration of ascites or the development of hepatic encephalopathy are often prevailing. Fever and peripheral blood leukocytosis as well as abdominal sings of peritonitis are not rarely completely missing. There is a strong suspicion of SBP with an ascitic polymorphonuclear count of greater than 500/mm3. Determination of lactate and pH in the ascitic fluid can increase diagnostic sensitivity and specificity if the leukocyte count is dubious. Gram negative rods predominate with over 70% whereas anaerobic organisms appear to be very rare. A 49 year old patient is presented and diagnostic and therapeutic strategies reviewed. In view of the high mortality every clinical deterioration of patients with cirrhosis should alert the physician of the presence of SBP.

Resistant strains of Klebsiella pneumoniae were found in increasing frequency as a cause of nosocomial infection in an intensive care unit between July and October 1990. The isolated strains had an almost identical biochemical profile, showed a similar pattern of antibiotic resistance, and produced type SHV2-broad-spectrum betalactamase. Thus, it was assumed that the isolates were copies of identical strains, causing an outbreak of nosocomial infections. The bacteria were resistant to third-generation cephalosporins, such as cefotiam, cefotaxime and ceftriaxone, and also to aminoglycosides and acylaminopenicillins. Approximately half of the strains were resistant to ceftazidim and aztreonam. The bacteria were sensitive in vitro to ciprofloxacin, imipenem, latamoxef and cefotetan. During three months, 10% (11) of all patients became infected; four of these patients (36%) died from septicemia. After conventional hygiene programs had failed to stop the outbreak, the intensive care unit was closed and disinfected, a measure, which effectively interrupted the infection.

In three experimental series the reliability of contemporary microbial indicators has been verified. It was shown that about 30% colonies growing on the Endomedium belongs not to family Enterobacteriaceae. The share of the so-called faecal coliforms growing at 44 degrees C is 54.6%. In comparison with the initial cultivations at the second passage this part increasing at about 126%. In waters of various quality is the viability of E. coli the smallest. Also on the Mc Conkey medium at 44 degrees C disappeared the colonies in order: E. coli (3-14 days), K. pneumoniae (3-21 days) C. freundii (21-28 days). This results brings an evidence that the existing indicator system for water quality should be revised.

In vitro Evaluation of BRL 17421 (Temocillin), a New Penicillin. The in vitro antibacterial activity of BRL 17421 (temocillin), a new penicillin, was determined in quantitative serial broth dilution tests and was compared to that of mezlocillin, piperacillin, cefazolin and cefotaxime against 751 clinical isolates of the Enterobacteriaceae family. In addition, the sensitivity of 211 mezlocillin-resistant gram-negative rods to BRL 17421 was also determined. Temocillin exhibited a high level of antibacterial activity against various bacterial species of the Enterobacteriaceae family, including isolates resistant to mezlocillin. The 90% MICs against Escherichia coli, Klebsiella pneumoniae, Citrobacter freundii, Enterobacter cloacae, Salmonella spp., Yersinia spp. and indole-negative and indole-positive Proteus strains ranged from 0.5 mg/l to 16 mg/l. Concentrations of 16 mg/l were required to inhibit 80% of the Serratia marcescens strains; some isolates were resistant. No significant difference between MIC and MBC values was observed.