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Background: Fever in patients with neutropenia may indicate a serious/lethal underlying bacterial sepsis. In Norway, penicillin G in combination with an aminoglycoside is the therapy of choice for this indication. In most countries, empiric monotherapy starts with a broadspectrum betalactam antibiotic., Material and Methods: Review of the literature and expert opinion identified five Norwegian studies evaluating therapy with penicillin in combination with an aminoglycoside in febrile neutropenia. These studies are presented and assessed., Results: Mortality in febrile neutropenia is approximately 5 % both in the Norwegian studies and in larger international trials. Therapy which starts with penicillin and an aminoglycoside needs to be modified more frequently(60 %) than when it starts with broadspectrum betalactam monotherapy (40 %). The Norwegian studies span 20 years. Clinical blood culture isolates from this group of patients show stable resistance patterns., Interpretation: In spite of methodological weaknesses, all the studies have the same conclusion: penicillin G in combination with an aminoglycoside is an effective and safe initial empiric therapy provided it is modified when the clinical course is unsatisfactory.

Background: Antibiotic resistance has progressed over many decades and is increasingly problematic. This paper gives a short summary of antibiotic resistance and its biology., Material and Methods: The authors have worked in this field for many years. References to major overviews and important work are given, but no systematic literature search has been done., Results: Development of resistance is driven by positive selection of resistant clones of bacteria. There are multiple, often interlinked molecular mechanisms behind this resistance, and they all lead to a less effective interaction between antibiotics and their target., Interpretation: Many observations of antibiotic resistance phenomena and their development over the last decades indicate that the problem is substantial, persisting and increasing. It will probably have an important impact on many medical disciplines in the future. Work to counteract this development is needed in every medical field in order to halt and hopefully counteract resistance development as strongly as we can.

Background: Transmission of group B Steptococci from mother to child during delivery may cause serious disease in some children, but this can be prevented by use of antibiotic treatment during delivery. We have estimated how antibiotic treatment of all pregnant carriers of group B streptococcus during delivery would affect the total antibiotic use in Norway., Material and Methods: We estimated the use of penicillin G for treatment of 10 %, 20 % and 30 % of streptococcus carriers among those delivering. The Medical Birth Registry was used to obtain number of births and the Norwegian Drug Wholesalers Database to obtain total use of the various substances., Results: If 30 % of delivering women were carriers of group B streptococcus and treated with penicillin G, the treatment would equal 2.8 % of today's total use of penicillin G and 0.09 % of the total use of the whole group of beta-lactam antibacterial agents, penicillins., Interpretation: Prophylactic antibiotic treatment of pregnant carriers of group B streptococcus during delivery would not lead to a substantial change in the current antibiotic use. The possibility of increasing antibiotic resistance should not be a main argument against using antibiotics in prevention of group B streptococcus infection in newborns.

Background: Invasive pneumococcal disease (IPD) is an important cause of morbidity and mortality in Norwegian children., Material and Methods: This retrospective study included all children (under 16 years) with isolates of Streptococcus pneumoniae from a normally sterile site admitted to the Department of Paediatrics at Ullevaal University Hospital in the period 1998 to 2004. We studied the epidemiology, predisposing factors, clinical picture, antimicrobial resistance, outcome of IPD and the theoretical coverage of the 7-valent conjugate pneumococcal vaccine (PCV7) in these children. The isolates were tested for antimicrobial susceptibility, serogrouped and serotyped., Results: 68 children were identified; 31 of them had one or more predisposing factors. Six children died, all of them had a predisposing factor. Six of the seven children who survived with sequelae were previously healthy. 67 of 68 isolates were fully susceptible to benzyl penicillin and 13 isolates showed intermediate susceptibility or resistance to erythromycin. Serogroups or serotypes were obtained in 66 children. 24 (36.8%) children fulfilled the criteria for PCV7. 35 (51.1%) children had serotypes covered by the vaccine. Only 12 (17.6%) fulfilled the criteria for PCV7 and had serotypes covered by it. Four of the six children who died had serotypes covered by PCV7., Interpretation: Invasive pneumococcal disease is a serious condition in children and vaccination can prevent disease in many children.

Background: In Norway, approximately 35% of surgery laboratories use dip-slides to assess bacteriuria. From 2000 to 2004 the Norwegian centre for quality assurance in primary health care (NOKLUS) has evaluated how office laboratories assess urine dip-slides., Material and Methods: Once a year participants receive inoculated and incubated dip-slides to read and report to NOKLUS. Target values are determined from assessments in four large microbiological laboratories., Results: Knowledge of reading dip-slides is insufficient. Only 40% of the participants in the quality assessment program evaluate whether growth is gram-negative or gram-positive, or take into account whether the growth is mono-bacterial or mixed. Many participants send the dip-slide to microbiological laboratories for evaluation whenever growth is significant, also when the growth is mixed., Interpretation: The programme shows that Norwegian office laboratories do not use all the information they can get from the dip-slide. There is a need for guidelines on this topic in general practice.

Background: Children undergoing transplantation or treatment for cancer have periods with severe immunosuppression; hence they are very susceptible to infections. A bacterial infection can rapidly become life threatening, and it is crucial to promptly start antibiotic treatment., Materials and Methods: The background for this article is a two-day discussion among Norwegian paediatricians about infections in immunosuppressed children. In addition we have reviewed the literature by searches in PubMed, reference books and international guidelines., Results and Interpretation: When a neutropenic patient becomes febrile, one should quickly do a thorough clinical examination, secure relevant microbiological samples, and start treatment with broad-spectrum antibiotics. As standard treatment for Norwegian children we recommend a combination of intravenous ampicillin and gentamicin. Patients who have clinical signs of septic shock should be given cefotaxime and gentamicin. If they get worse or show no signs of recovery after 3 to 5 days, a change to monotherapy with cefotaxime is recommended. Patients already treated with cefotaxime should be switched to meropenem, possibly in combination with vancomycin. Antifungal and/or anti-anaerobic treatment should also be considered.

During the last decade antimicrobial resistant pathogens have become a major medical problem. Internationally, multiresistant enterococci have increased nosocomial morbidity and mortality. Such strains are often resistant to ampicillin, aminoglycosides, and glycopeptides such as vancomycin. The spread of these strains has been shown to correlate to the use of antibiotics and the practice of suboptimal infection control within health care facilities. The current situation in Norwegian hospitals is presented, including the only six cases with infections and the three carriers of vancomycin resistant enterococci found to date. Surveillance in the hospitals shows that such strains are uncommon in non-infected patients. To maintain this favourable situation it is necessary to continue to practice effective methods of infection control and to employ sound antibiotic policies.

Only 229 cases of gonococcal infection were recorded in Norway in 1994 (population 4.3 million), as against more than 14,000 cases two decades before. Up to now aminopenicillins with probenecid have been the standard treatment. In 1994, 29% of the reported cases of gonococcal infection were caused by a betalactamase-producing strain. We now recommend treating uncomplicated gonococcal infections with a single oral dose of ciprofloxacin 500 mg, or ofloxacin 400 mg. Pregnant or lactating women should receive intramuscular injections of cefotaxim 500 mg, or spectinomycin 2 g. Test-of-cure is essential. Its main purpose is to discover resistant strains and reinfections. Thorough contact tracing is more important than ever. Culture verification, susceptibility testing and test-of-cure in all cases will influence the continuous reevaluation of these guidelines.

The article summarizes the epidemiology of disease caused by Streptococcus pyogenes in Norway during the last two decades, with emphasis on trends since the late 1980s. The description is based on the National Notification System for Infectious Diseases, and on microbiological data. The nationwide outbreak in 1987-88, caused mainly by M-1 organisms, was followed by several years with remarkably low incidences of invasive disease. However, since late in 1992 there has again been a nationwide outbreak that reached even higher numbers of invasive cases than the one in 1988. While 106 cases of systemic group A streptococcal disease were recorded in 1988, the numbers for 1993 and 1994 were 143 and 188 respectively (population 4.3 million). No change has taken place in the laboratory-based notification system that could explain the observed phenomena. Previously seldom observed clinical manifestations, such as fulminant septicaemia, necrotising fasciitis and pneumonia with empyema, were again recorded; as during the 1988 outbreak.

We surveyed 472 cases of culture-confirmed systemic pneumococcal disease that were reported to the Norwegian Notification System for Infectious Diseases during a 12-month period in 1992-93. The clinicians in charge of the patients filled in a questionnaire providing information on underlying disease and outcome for 461 (98%) of the patients. Eight of these patients were splenectomized; all of them more than ten years before. Four died, two survived but had serious sequelae, and two survived without obvious sequelae upon discharge from hospital. Using a rough estimate of the prevalence of unvaccinated splenectomized persons in Norway, we estimate that this group, compared to the normal population, has a relative risk of 25 of developing systemic pneumococcal disease and a relative risk of 75 of dying from pneumococcal disease. The serotype of the pneumococcal strain that caused the disease was determined for seven of the eight patients. All serotypes were represented in the 23-valent pneumococcal polysaccharide vaccine. We strongly recommend that doctors trace and vaccinate splenectomized individuals.

Between 1986 and 1991, 29 patients with malignant lymphomas were treated with total body irradiation and high-dose chemotherapy followed by autologous bone marrow transplantation at the Norwegian Radium Hospital. Owing to treatment-induced bone marrow toxicity, the leucocyte count in peripheral blood rapidly fell to zero. The aplastic phase lasted for 25 days (median). All patients experienced fever in the posttransplant period and needed broad-spectrum antibiotics. 12 patients had documented bacteremia, mostly with Gram-positive isolates. There were seven cases of documented focal infections, and antibiotic-associated colitis was seen in two cases. Other complications included bleedings and skin rashes. Four patients died in the post-transplant period from complications related to the cytotoxic treatment. We discuss guidelines for antimicrobial treatment of suspected and confirmed infections in neutropenic patients.

Infections due to Streptococcus pyogenes are varied and often difficult to diagnose. During the last few years the clinical manifestations of these infections and the treatment rationale have changed. New diagnostic tests have been introduced. The present article reviews the diagnostic possibilities based upon clinical findings, the doctor's own laboratory and the microbiological laboratory. Rapid immunological tests, differential leukocyte count and C-reactive protein are pointed out as potentially useful laboratory tools for the clinician.

Since 1987 the number of severe and fatal cases of group A-beta-hemolytic streptococci (GAS) infections has increased in Scandinavia. It therefore seems reasonable to stress the monitoring, diagnosis and treatment of infections caused by GAS. Treatment with phenoxymethylpenicillin for ten days is recommended for patients with uncomplicated disease. Patients with severe disease should be treated with benzylpenicillin intravenously. We discuss alternative antibiotics, treatment of immunological complications, and general hygienic precautions.

The article briefly surveys the epidemiology of Streptococcus pyogenes caused disease in Norway during the last 15 years based on notification data, with emphasis on the nation-wide outbreak in 1987-88 caused by mucoid M-1 organisms. During the season S. pyogenes infections was 60% higher than expected. The number of bacteraemia cases, many with fulminant septicaemia, showed an almost threefold increase compared with earlier years. Unusual clinical manifestations such as necrotising fasciitis, pneumonia with empyema, primary peritonitis and meningitis also occurred. We briefly review the known virulence factors of S. pyogenes in an attempt to improve our understanding of the shift in clinical manifestations and occurrence of the disease.