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The Dutch Working Party on Antibiotic Policy in collaboration with the Dutch Association of Chest Physicians, the Dutch Society for Intensive Care and the Dutch College of General Practitioners have updated their evidence-based guidelines on the diagnosis and treatment of community-acquired pneumonia (CAP) in adults who present to the hospital. This 2016 update focuses on new data on the aetiological and radiological diagnosis of CAP, severity classification methods, initial antibiotic treatment in patients with severe CAP and the role of adjunctive corticosteroids. Other parts overlap with the 2011 guideline. Apart from the Q fever outbreak in the Netherlands (2007-2010) no other shifts in the most common causative agents of CAP or in their resistance patterns were observed in the last five years. Low-dose CT scanning may ultimately replace the conventional chest X-ray; however, at present, there is insufficient evidence to advocate the use of CT scanning as the new standard in patients evaluated for CAP. A pneumococcal urine antigen test is now recommended for all patients presenting with severe CAP; a positive test result can help streamline therapy once clinical stability has been reached and no other pathogens have been detected. Coverage for atypical microorganisms is no longer recommended in empirical treatment of severe CAP in the non-intensive care setting. For these patients (with CURB-65 score >2 or Pneumonia Severity Index score of 5) empirical therapy with a 2nd/3rd generation cephalosporin is recommended, because of the relatively high incidence of Gram-negative bacteria, and to a lesser extent S. aureus. Corticosteroids are not recommended as adjunctive therapy for CAP.

The Dutch Working Party on Antibiotic Policy (SWAB) and the Dutch Association of Chest Physicians (NVALT) convened a joint committee to develop evidence-based guidelines on the diagnosis and treatment of community acquired pneumonia (CAP). The guidelines are intended for adult patients with CAP who present at the hospital and are treated as outpatients as well as for hospitalised patients up to 72 hours after admission. Areas covered include current patterns of epidemiology and antibiotic resistance of causative agents of CAP in the Netherlands, the possibility to predict the causative agent of CAP on the basis of clinical data at first presentation, risk factors associated with specific pathogens, the importance of the severity of disease upon presentation for choice of initial treatment, the role of rapid diagnostic tests in treatment decisions, the optimal initial empiric treatment and treatment when a specific pathogen has been identified, the timeframe in which the first dose of antibiotics should be given, optimal duration of antibiotic treatment and antibiotic switch from the intravenous to the oral route. Additional recommendations are made on the role of radiological investigations in the diagnostic work-up of patients with a clinical suspicion of CAP, on the potential benefit of adjunctive immunotherapy, and on the policy for patients with parapneumonic effusions.

The susceptibility of 14 species of 115 Gram-positive anaerobic cocci (GPAC) was determined for 14 antibiotics. To assure correct identification, strains were genotypically identified by fluorescence in situ hybridization and sequencing. Susceptibility differences (MIC₅₀ and MIC₉₀) for penicillin G, clindamycin, tigecycline, levofloxacin, amoxicillin-clavulanic acid, cefoxitin, ertapenem, meropenem, metronidazole, and doxycycline were found for the three clinically most relevant GPAC species: Finegoldia magna, Parvimonas micra, and Peptoniphilus harei.

The Dutch Working Party on Antibiotic Policy (Stichting Werkgroep AntibioticaBeleid, SWAB) was founded in 1996 as an initiative of the Society for Infectious Diseases, the Dutch Society for Medical Microbiology, and the Dutch Association of Hospital Pharmacists. Its primary goal is to contribute to the containment of antimicrobial resistance and the expanding costs incurred for the use of antibiotics. SWAB is the Intersectoral Coordinating Mechanism (ICM) for the Netherlands, and it is at present the National Antimicrobial Resistance (AMR) Focal Point. It coordinates the national surveillance of antibiotic resistance, in collaboration with the National Institute for Public Health and the Environment(RIVM), coordinates the surveillance of the use of antibiotics,and runs a guideline development programme. Information about consumption of antimicrobial agents and antimicrobial resistance among medically important bacteria is presented annually in NethMap. Over the past decade, outpatient consumption of antibiotics has risen only slightly, but in the hospital setting there was an overall significant increase in antibiotic use, due mainly to the steady reduction in the average length of patient hospital stays. In 2006 we introduced our electronic national antibiotic guide 'SWAB-ID' for the antibiotic treatment and prophylaxis of common infectious diseases in hospitals.

Microbial infections constitute an important reason for medical treatment, especially in dentistry. Ideas about the role played by bacteria in the development of diseases have changed steadily during the past centuries. At the present time much attention is being devoted to the role of biofilms due to their illness-causing influence with respect to stitches on hard tissue and on oral implants, knee-, hip-, and voice prostheses. In biofilms, bacteria function and communicate in organized extrapolymeric structures, attached to a surface. Biofilms provide bacteria with protection against the host's immune system and antibacterial chemicals. By gaining insights into the creation and functioning of biofilms, it will be possible to develop better antibacterial therapies.

The Dutch Working Party on Antibiotic Policy (SWAB) has revised the 1998 guideline for community-acquired pneumonia (CAP) in light of changing resistance patterns for common pathogens and new developments in epidemiology, diagnostic testing and treatment strategies. The current guideline is applicable to both primary and inpatient care, and has been developed by delegates of all professional organisations involved in the treatment of CAP, following recommendations for evidence-based guideline development. Assessment of a patient's 'severity of illness' at presentation is considered important when choosing an optimal empirical antibiotic regimen for CAP. Severely-ill patients should be treated with antibiotics covering the most important expected pathogens, including Legionella. Assessment of the severity of illness may be facilitated by the use of validated scoring systems like the pneumonia severity index and the 'confusion, urea, respiratory-rate, blood-pressure, 65-years-of-age' (CURB-65) score. Patients can also be stratified based on their location during treatment: in the community, a normal ward or an intensive-care unit. Legionella urine antigen testing is considered an important tool in the process of deciding on an optimal antibiotic regimen for CAP. Empirical therapy should be replaced with pathogen-directed therapy if the causative agent is identified.

The Dutch Working Party on Antibiotic Policy (SWAB) develops evidence-based guidelines, aimed at optimalisation of antibiotic use and limitation of the spread of antimicrobial resistance. A revision of the SWAB guideline for the treatment of community-acquired pneumonia (CAP), published in 1998, was considered necessary because of changes in resistance patterns and new insights into the epidemiology, diagnostics and treatment of CAP. In contrast to the former version, this guideline is transmural and has been drawn up according to the recommendations for evidence-based guideline development by a multidisciplinary committee consisting of experts from all relevant professional societies. The 'severity of disease' exhibited by the patient with pneumonia on admission is considered important for the choice of the optimum empirical treatment strategy. Severely ill patients are treated empirically with a drug directed against multiple potential pathogens, including Legionella spp. Classification according to 'severity of disease' can be accomplished with a validated scoring system (Pneumonia Severity Index or CURB-65 score) or pragmatically, based on the site of treatment: an outpatient setting, a clinical ward or an intensive care unit. The Legionella urine antigen test plays an important role in decisions on the choice of initial antibiotic treatment.

Assessment procedures for adherence to a guideline must be reliable and credible. The aim of this study was to explore the reliability of assessment of adherence, taking account of the professional backgrounds of the observers. A secondary analysis explored the impact of case characteristics on assessment. Six observers (two hospital pharmacists, two internists and two clinical microbiologists) assessed a random sample of 22 prescriptions made to infectious disease cases admitted to a department of internal medicine between February and August 2001. Agreement between observers with regard to adherence of these prescriptions to guideline recommendations concerning drug choice, duration of treatment, dosage and route of administration was measured using Cohen's kappa. Case characteristics were compared between cases where observers agreed and disagreed with two-sided Fisher's exact test. Agreement between all professionals was moderate for drug choice (0.59), fair for duration of therapy (0.36), moderate for dosage (0.48), and fair for route of administration (0.37). Agreement on drug choice was good within (0.75 and 0.83) and between (0.74) the internists and the hospital pharmacists, but was less within (0.31) the clinical microbiologists and between the clinical microbiologists and the internists (0.44) and the hospital pharmacists (0.42). Within the clinical microbiologists, agreement was good for dosage (0.79) and route of administration (0.66). There was frequent disagreement between observers regarding cases with combination therapy and non-immunocompromised patients. Despite the small number of cases, our results suggest that internists and hospital pharmacists can reliably be used to assess adherence for drug choice. The level of agreement seems to be affected by combination therapy and the immune status of the patient.

Objectives: To forecast trends in resistance to penicillin and erythromycin among Streptococcus pneumoniae in Europe., Methods: Since 1999, the European Antimicrobial Resistance Surveillance System (EARSS) has collected routine antimicrobial susceptibility test results of S. pneumoniae. To observe and predict changes of reduced susceptibility over time, we used a multinomial logistic regression model., Results: Large variations in penicillin and erythromycin non-susceptibility were observed between countries, and reduced susceptibility to erythromycin (17%) has become more frequent than reduced susceptibility to penicillin (10%) in Europe overall. An overall decrease in single penicillin non-susceptibility, but an increase in dual non-susceptibility was observed, indicating a shift of single penicillin to combined non-susceptibility with erythromycin. By 2006, the proportion of single erythromycin and dual non-susceptibility could increase to as much as 20.4% and 8.9%, respectively., Conclusions: Our results indicate that appropriately dosed beta-lactams for empirical therapy are still the treatment of choice, and that macrolides should be used with prudence.

Regional differences of antibiotic use and antibiotic resistance in the fecal indicator bacteria Escherichia coli and enterococci were determined in different cities in the south, west, and north of The Netherlands. In 1999, differences in antibiotic consumption were observed between the different regions: 11.19, 10.84, and 7.16 DDD (defined daily dosage) per 1,000 inhabitants per day, respectively. No significant regional differences were found in the prevalence of antibiotic resistance for both E. coli and enterococci. However, the differences in antibiotic consumption observed might lead to changes in antibiotic resistance in the near future. Surveillance of antibiotic use and antibiotic resistance is strongly recommended to control the development of antibiotic resistance because it provides epidemiological data to set up and control antibiotic guidelines.

This study examined whether the simultaneous presence of metronidazole-susceptible and -resistant Helicobacter pylori colonies in a single biopsy specimen is caused by a multiple strain infection with a susceptible and a resistant strain or by two subpopulations within a single strain. Single colonies obtained from seven biopsy specimens known to harbour both susceptible and resistant Helicobacter pylori were fingerprinted by restricted fragment length polymorphism typing of the ureC gene and by the random amplified polymorphic DNA procedure. Metronidazole susceptibility was determined by the E test. The results indicated that the occurrence of metronidazole-resistant and metronidazole-susceptible bacteria within a single biopsy does not imply the presence of a multiple strain infection with one resistant and one sensitive strain.

One approach for prosthetic vascular surgery is to continue antimicrobial prophylaxis while intravascular lines and catheters are in place. However this may give rise to antimicrobial resistance in the colonizing bacterial flora. We studied 37 patients undergoing vascular surgery, who received either co-amoxyclav for three days (group 1), ofloxacin plus metronidazole for three days (group 2) or for one day (group 3), respectively. Seventeen hospitalized patients not undergoing surgery or receiving antibiotics were studied as controls. In groups I and II there was a significant decline in susceptibility to cloxacillin (12.8% respectively 23.6%) and ofloxacin (0.5% and 85% respectively) in skin staphylococci. The results from group 3 were intermediate. Molecular typing showed that the patient's susceptible community-derived strains were replaced by genetically unrelated resistant strains, probably hospital derived. Long-term prophylaxis should be avoided as colonization occurs with resistant strains.

The problem of international spread of bacterial resistance requires development of a strategy at worldwide or at least at European level. Clinically relevant monitoring systems for resistance and use of antibiotics have to be implemented to support the guidelines on prescription of antibiotics. Every hospital should establish an 'antibiotics team' controlling the prescription of antimicrobials and the observance of local formulary agreements. Veterinary use of growth promoting antimicrobials related to substances used in human medicine should be terminated. Future research should be aimed at resolving the problem of resistance to antimicrobials.

The Health Council of the Netherlands has issued a report on the risk of development of resistance among bacteria as result of the use of antibiotics as growth promotors in livestock farming. The committee appointed by the Health Council conclude that the use of antimicrobial growth promotors contributes to the problem of resistance among human pathogens. The conclusions are based on evidence regarding the development of resistance in livestock as the result of the use of antimicrobial growth promotors, the possibility of colonisation/infection of humans with resistant bacteria from the intestinal flora of productive livestock, and the transfer of resistance genes from livestock bacteria to human pathogenic microorganisms. Effective measures for the limitation of the public health risk should focus on termination of the use of antimicrobial growth promotors that confer resistance to (related) antibiotics currently used (or which will be available) to treat patients suffering from bacterial infections. In addition, the committee advised ending the use of antimicrobial growth promotors in 3 years.

In a comparative study on the efficacy of two surgical treatment procedures, 90 patients diagnosed with chronic maxillary sinusitis received antimicrobial prophylaxis. Maxillary sinus fluid samples were taken from these 90 patients before the initiation of antimicrobial prophylaxis, and were cultured for aerobic and anaerobic bacteria. In 81% of all samples, bacterial growth was present. Anaerobic bacteria were present in 29% of the cases (5% pure anaerobic and 24% mixed aerobic and anaerobic). Predominant aerobic bacteria were staphylococci, in 42% of all samples (mainly coagulase-negative), and streptococci (32%). Predominant anaerobic bacteria were Propionibacterium species (18%) and Gram-negative rods (9%). The antimicrobial susceptibility was determined for 20 antibiotics, and the beta-lactamase production was investigated. The prevalence of beta-lactamase-producing bacteria was unexpectedly high (isolated from 36% of all patients). The findings in this study indicate that not all antimicrobial agents used against upper respiratory tract infections are suitable for treatment of this group of patients when the susceptibility of bacteria present in sinus fluid is taken into account. The high prevalence of beta-lactamase-producing bacteria could influence the course of the disease, due to the breakdown of antibiotics by such strains. Recommendations are given for criteria to use when choosing antimicrobial agents to treat bacterial infections it) patients with chronic maxillary sinusitis.

The correlation between antibiotic consumption, expressed in defined daily doses (DDD), and antibiotic resistance rates was studied, using 976 isolates of coagulase negative staphylococci (CNS) from human pathological material. Data from four hospitals, including 14 participating departments, were analysed for this purpose. Susceptibility tests were performed according to Dutch national standards, except for methicillin, which for the majority of isolates was tested according to adapted NCCLS standards. Resistance to methicillin was most frequent in Staphylococcus epidermidis (29%) and S. haemolyticus (16%). Among the departments, thoracic surgery (29-47%), surgical intensive care (68%) and neonatology (32%) scored highest. Significant correlations were found between percentages of methicillin resistance in CNS and consumption (DDD/month/bed) of (flu)cloxacillin (P0.008), of cephalosporins (P0.01) and of gentamicin (P0.005). (Flu)cloxacillin was used mainly prophylactically, cephalosporins and gentamicin therapeutically. Results were similar for S. epidermidis (n = 639) alone. There was no significant correlation between consumption and resistance to trimethoprim, erythromycin (P0.08) or gentamicin (P0.09). Analysis of data from individual patients showed significant differences in proportions of methicillin resistance rates in CNS, between use and non-use of penicillinase resistant beta-lactams or gentamicin. It is concluded that clinical use of both (flu)cloxacillin and cephalosporins selects for methicillin resistant CNS.

Faecal carriage rates for aerobic gram-negative bacilli and for antibiotic-resistant Escherichia coli were determined in samples of the Dutch urban population. Of the 741 people studied, 64 were under 1 year old (infants), 53 were 1-5 years old, and there were approximately 200 in each of the age-ranges 6-17 years, 18-49 years and 50-80 years. Carriage rates of E. coli were similar (87-93%) in all age groups, but Klebsiella and Enterobacter species were found more often in specimens from infants and young children than in those from older people. E. coli strains resistant to tetracycline, ampicillin, or sulphamethoxazole or to any one or more of them were detected in 42%, 26%, 46% and 66% respectively of the specimens found to contain E. coli. The corresponding figures for the finding of E. coli populations that were predominantly resistant to tetracycline, ampicillin or sulphamethoxazole were 12%, 6% and 20%. The frequency of resistance to any of these drugs was not related to age or sex of the subjects. All E. coli isolates were sensitive to gentamicin. Among the 577 subjects aged 6-80 years from whose samples E. coli was isolated were 19 who had taken antibacterial drugs in the previous 30 days and 11 who were involved in cattle farming; carriage rates for tetracycline-resistant and sulphonamide-resistant E. coli were significantly higher among these 30 than in the other 547.

Resistance of faecal Escherichia coli to ampicillin, tetracycline, sulphamethoxazole and gentamicin was studied in patients admitted to seven different departments in two hospitals. The resistance of ampicillin, tetracycline and sulphamethoxazole in the seven patient groups was 27-57%, 26-56% and 35-63%, respectively. Resistance to gentamicin was found in only one department. An E. coli flora predominantly resistant to ampicillin, tetracycline or sulphamethoxazole (greater than 50% of the E. coli strains in a faecal sample resistant) was found in 10-38%, 4-30% and 21-35% of the samples. A cross-sectional study focusing on the influence of the use of antimicrobial agents on the occurrence of resistant strains revealed a positive correlation between the annual turnover of broad-spectrum penicillins in various departments and the occurrence of predominantly ampicillin-resistant E. coli strains in these departments.