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Norovirus is the leading cause of outbreaks of acute viral gastroenteritis. We carried out this study to investigate outbreaks in long-term care facilities reported in 2017 and 2018 in Catalonia (Spain). The characteristics of the centers, exposed persons and the genogroups responsible were analyzed. Viral loads were estimated. The attack rate (AR) of the outbreaks studied, and the rate ratio (RR) and the odds ratio (OR) and their 95% confidence intervals as measures of association were calculated. The mean cycle thresholds were compared using the t-test for independent means. We included 30 outbreaks (4631 exposed people). The global AR was 25.93%. The RR of residents vs. staff was 2.28 (95% CI 2.0–2.6). The RR between AR in residents with total or severe dependence vs. residents with moderate, low or no-dependence was 1.23 (95% CI 1.05–1.45). The AR were higher in smaller centers than in larger ones (38.47% vs. 19.25% and RR 2; 95% CI 1.82–2.2). GII was responsible for 70% of outbreaks. No association was found between the genogroup and presenting symptoms (OR 0.96; 95% CI 0.41–2.26). Viral loads were higher in symptomatic than in asymptomatic patients (p = 0.001). This study was funded by Instituto de Salud Carlos III through the project PI16/02005 (Co-funded by European Regional Development Fund “Investing in your future”) and the Catalan Agency for the Management of Grants for University (AGAUR Grant No. 2017/SGR 1342). The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Acute infectious gastroenteritis is an important illness worldwide, especially on children, with viruses accounting for approximately 70% of the acute cases. A high number of these cases have an unknown etiological agent and the rise of next generation sequencing technologies has opened new opportunities for viral pathogen detection and discovery. Viral metagenomics in routine clinical settings has the potential to identify unexpected or novel variants of viral pathogens that cause gastroenteritis. In this study, 124 samples from acute gastroenteritis patients from 2012&ndash, 2014 previously tested negative for common gastroenteritis pathogens were pooled by age and analyzed by next generation sequencing (NGS) to elucidate unidentified viral infections. The most abundant sequences detected potentially associated to acute gastroenteritis were from Astroviridae and Caliciviridae families, with the detection of norovirus GIV and sapoviruses. Lower number of contigs associated to rotaviruses were detected. As expected, other viruses that may be associated to gastroenteritis but also produce persistent infections in the gut were identified including several Picornaviridae members (EV, parechoviruses, cardioviruses) and adenoviruses. According to the sequencing data, astroviruses, sapoviruses and NoV GIV should be added to the list of viral pathogens screened in routine clinical analysis.

Norovirus infections are a leading cause of acute gastroenteritis outbreaks worldwide and across all age groups, with two main genogroups (GI and GII) infecting humans. The aim of our study was to investigate the occurrence of norovirus in saliva samples from individuals involved in outbreaks of acute gastroenteritis in closed and semiclosed institutions, and its relationship with the virus strain, virus shedding in stool, the occurrence of symptoms, age, and the secretor status of the individual. Epidemiological and clinical information was gathered from norovirus outbreaks occurring in Catalonia, Spain during 2017–2018, and stool and saliva samples were collected from affected and exposed resident individuals and workers. A total of 347 saliva specimens from 25 outbreaks were analyzed. Further, 84% of individuals also provided a paired stool sample. For GII infections, norovirus was detected in 17.9% of saliva samples from symptomatic cases and 5.2% of asymptomatic individuals. Positivity in saliva occurred in both secretors and nonsecretors. None of the individuals infected by norovirus GI was positive for the virus in saliva. Saliva positivity did not correlate with any of the studied symptoms but did correlate with age ≥ 65 years old. Individuals who were positive in saliva showed higher levels of virus shedding in stool. Mean viral load in positive saliva was 3.16 ± 1.08 log10 genome copies/mL, and the predominance of encapsidated genomes was confirmed by propidium monoazide (PMA)xx-viability RTqPCR assay. The detection of norovirus in saliva raises the possibility of oral-to-oral norovirus transmission during the symptomatic phase and, although to a lesser extent, even in cases of asymptomatic infections.

Describe secular trends in the epidemiology and outcome of Clostridium difficile infection (CDI) at a tertiary hospital.All consecutive primary CDI episodes in adults (January 2006-December 2015) were included. CDI was diagnosed on the presence of diarrhoea and a positive stool test for C. difficile toxin A and/or B. To define trends, a time-series analysis was performed using yearly data on demographics, clinical characteristics, management, antimicrobial treatment, and outcome of CDI. Patients were followed-up for three months after the diagnosis.There were 724 CDI episodes. Over the period from 2006 to 2015, the incidence rose from 0.18 episodes/1000 admissions to 0.26 episodes (relative rate [RR] 1.43; 95%CI, 1.02-2.00; P = 0.035). Median Charlson comorbidity index increased from 2 (IQR 1-3) to 4 (IQR 2-4) (RR 1.65; 95%CI, 1.12-2.41; P = 0.005). Overall, 80.4% of patients received proton pump inhibitors (PPIs) prior to CDI, and the percentage of PPI discontinuations rose from 2.3% to 20.4% (RR 8.80; 95%CI 1.20-64.36; P = 0.006). Management of non-Clostridium antibiotics also changed: antibiotic withdrawals or switches increased from 4.2% to 29.2% (RR 7.00; 95%CI 1.68-29.15, P = 0.001). Regarding CDI treatment, the percentage of patients treated with metronidazole decreased (88.9% vs 52.6%) (RR 0.59 (0.48-0.73), P 0.001), whereas the percentage receiving vancomycin increased (1.9% vs 32.6%) (RR 17.62 (2.47-125.49), P 0.001). The percentages of cures, deaths, and first recurrences did not significantly change over the 10-year period.Changes in CDI management were associated with a stable prognosis (percentage of cures and first recurrences), even though affected patients had a greater number of comorbidities over time.

In April 2016, an outbreak of gastrointestinal illness (4,136 cases) occurred in Catalonia, Spain. We detected high levels of norovirus genogroups I and II in office water coolers associated with the outbreak. Infectious viral titer estimates were 33-49 genome copies/L for genogroup I and 327-660 genome copies/L for genogroup II.

This study aimed to evaluate the effectiveness and safety of teicoplanin for treating enterococcal infective endocarditis (EIE). A retrospective analysis of a prospective cohort of definite EIE patients treated with teicoplanin in a Spanish referral centre (2000-2017) was performed. The primary outcome was mortality during treatment. Secondary outcomes were mortality during 3-month follow-up, adverse effects and relapse. A total of 22 patients received teicoplanin, 9 (40.9%) as first-line (8 Enterococcus faecium and 1 Enterococcus faecalis) and 13 (59.1%) as salvage therapy (13 E. faecalis). Median (IQR) age was 71.5 (58.3-78) years and Charlson comorbidity index was 4.5 (3-7). Five (22.7%) affected prosthetic valves. Median duration of treatment in survivors was 53 (42.5-61) days for antibiotics and 27 (17-41.5) days for teicoplanin [median dose 10 (10-10.8) mg/kg/day]. Reasons for teicoplanin use were resistance to β-lactams (40.9%), adverse events with previous regimens (31.8%) and outpatient parenteral antimicrobial therapy (OPAT) (27.3%). Teicoplanin was withdrawn due to adverse events in 2 patients (9.1%). Five patients (22.7%) died during treatment: four in the first-line (three with surgery indicated but not performed) and one in the salvage therapy group (surgery indicated but not performed). Two deaths (11.8%) occurred over the 3-month follow-up. There were no relapses during a median of 43.2 (22.1-69.1) months. Teicoplanin can be used as an alternative treatment for susceptible E. faecium IE and as a salvage therapy in selected patients with E. faecalis IE when adverse events develop with standard regimens or to allow OPAT.

SUMMARYWe investigated an outbreak of norovirus that affected students and teachers of a high school in Lleida, Spain through various transmission mechanisms. A case-control epidemiological study of the risk of disease and the relative importance of each mode of transmission was carried out. Cases and controls were selected from a systematic sample of students and teachers present at the school on 28 January. Faecal samples were taken from three food handlers and 16 cases. The influence of each factor was studied using the adjusted odds ratio (aOR) and the estimated population attributable risk (ePAR) with 95% confidence intervals (CI). We interviewed 210 people (42 cases, 168 controls). The proportion of symptoms in these individuals was nausea 78·6%, vomiting 59·5%, diarrhoea 45·2%, and fever 19·0%. The epidemic curve showed transmission for at least 4 days. The risk of disease was associated with exposure to food (aOR 5·8) in 66·1% of cases and vomit (aOR 4·7) in 24·8% of cases. Faecal samples from 11 patients and two food handlers were positive for norovirus GII.12 g. Vomit may co-exist with other modes of transmission in norovirus outbreaks and could explain a large number of cases.

Background A significant proportion of norovirus (NV) gastroenteritis outbreaks described in the Spanish literature have been because of contaminated food or water. Aim This study describes an outbreak of acute gastroenteritis because of NV in which there was person-to-person transmission. Materials and methods A retrospective cohort study was carried out; we established the case definition for primary and secondary cases. An epidemiological survey was designed, including possible food exposures, and clinical and laboratory data. Water and stool samples were taken from affected individuals and food handlers. The presence of NV was detected using a reverse transcription-PCR assay. We analyzed the risk of gastroenteritis using relative risk and its 95% confidence interval as the measure of association, and estimated the basic reproductive number (R-0). Results The primary attack rate was 45.0%, with no significant differences between sexes. The secondary attack rate during the camp stay was 22.7%. The basic reproductive number for 5 days was R-0=2.62. The most frequent symptoms were abdominal pain (85.7%) and vomiting (81.9%). Epidemiological analysis showed no association with food or drinking water. A total of 66.6% (8/12) of stool samples tested positive for NV (genogroup II). Conclusion Control measures in general, and hand hygiene in particular, should be extended to the families once the children return home, to prevent secondary cases in NV outbreaks. (C) 2014 Wolters Kluwer Health broken vertical bar Lippincott Williams & Wilkins.

Objectives: To compare the concordance of ceftaroline MIC values by reference broth microdilution (BMD) and Etest (bioMérieux, France) for MSSA and MRSA isolates obtained from PREMIUM (D372SL00001), a European multicentre study. Methods: Ceftaroline MICs were determined by reference BMD and by Etest for 1242 MSSA and MRSA isolates collected between February and May 2012 from adult patients with community-acquired pneumonia or complicated skin and soft tissue infections; tests were performed across six European laboratories. Selected isolates with ceftaroline resistance in broth (MIC >1 mg/L) were retested in three central laboratories to confirm their behaviour. Results: Overall concordance between BMD and Etest was good, with >97% essential agreement and >95% categorical agreement. Nevertheless, 12 of the 26 MRSA isolates found resistant by BMD scored as susceptible by Etest, with MICs ≤1 mg/L, thus counting as very major errors, whereas only 5 of 380 MRSA isolates found ceftaroline susceptible in BMD were miscategorized as resistant by Etest. Twenty-one of the 26 isolates with MICs of 2 mg/L by BMD were then retested twice by each of three central laboratories: BMD MICs of 2 mg/L were consistently found for 19 of the 21 isolates. Among 147 Etest results for these 21 isolates (original plus six repeats per isolate) 112 were >1 mg/L. Conclusions: BMD and Etest have good overall agreement for ceftaroline against Staphylococcus aureus; nevertheless, reliable Etest-based discrimination of the minority of ceftaroline-resistant (MIC 2 mg/L) MRSA is extremely challenging, requiring careful reading of strips, ideally with duplicate testing., 0, SCOPUS: ar.j, info:eu-repo/semantics/published

ResumenObjetivosInvestigar un brote de gastroenteritis que afectó a la población de València d’Àneu (Lleida).MétodosEstudio de cohortes sobre el consumo de agua de la red, de agua embotellada y de agua de manantiales. La cohorte se elaboró mediante contacto telefónico con todos los números privados del municipio. Se encuestó al 58,3% de la población censada (105/180) sobre diferentes consumos de agua, número de vasos consumidos diariamente y sintomatología. Se tomaron muestras de agua de la red municipal y de heces de diez enfermos. La implicación de cada agua consumida se estudió con el riesgo relativo (RR) y su intervalo de confianza del 95% (IC95%).ResultadosLa tasa de ataque global fue del 64,8% (68/105). La curva epidémica fue concordante con una exposición de 6 días. Resultó implicado el consumo de agua de suministro público (RR=4,2; IC95%: 1,5-11,9). Además, se constató una relación dosis-respuesta (χ2=34,1; p

Resumen Introduccion Desde la decada de 1990 se describen cepas de Staphylococcus aureus resistente a la meticilina adquirido en la comunidad (SARM-AC) que afectan con frecuencia a ninos y a adultos jovenes sin factores de riesgo y cuya incidencia en Espana esta en aumento. Metodos Se incluyo a los pacientes atendidos en el area pediatrica entre agosto de 2006 y enero de 2009 con cultivos positivos para SARM-AC. Los aislamientos de S. aureus se estudiaron mediante tecnicas convencionales, su sensibilidad antimicrobiana mediante tecnica de discodifusion y la presencia del gen mecA mediante reaccion en cadena de la polimerasa ( multiplex ). La presencia de la leucocidina de Panton-Valentine se determino mediante reaccion en cadena de la polimerasa convencional. Se estudio el estado de portador en los pacientes y sus familiares. Resultados Se recogieron 15 aislamientos de SARM-AC de 12 pacientes sin factores de riesgo (entre 6 dias y 14 anos de edad). Ocho requirieron ingreso. La mitad de los enfermos eran de poblacion no autoctona. La afectacion de piel y partes blandas fue la forma clinica mas frecuente (92%). Solo 2 tuvieron bacteriemia. Dos cepas tenian resistencia a macrolidos asociada a la resistencia a meticilina y una de ellas, ademas, a lincosamidas. Todas fueron productoras de leucocidina de Panton-Valentine. La evolucion fue favorable. Se detecto una agrupacion familiar de SARM-AC. Conclusion La infeccion por SARM-AC constituye una enfermedad emergente en nuestro medio. Su incidencia en Espana es aun baja, por lo que no se debe cambiar el tratamiento empirico de las infecciones cutaneas. El drenaje de las lesiones tiene un papel importante en su curacion. La clindamicina o el cotrimoxazol es el tratamiento de eleccion de las formas leves o moderadas. El control de la propagacion de SARM-AC constituye un nuevo reto en la actualidad.

Noroviruses are the most frequent cause of acute gastroenteritis in the community. In Catalonia, it is not clear how this type of viral gastroenteritis is evolving, and the objective of this prospective population-based study was to describe the incidence and epidemiological and clinical features of outbreaks of acute gastroenteritis due to norovirus in Catalonia between October 2004 and October 2005. Incidence rates were calculated using the estimated population of Catalonia in 2005. For each outbreak, the mode of transmission, the number of persons affected, demographic variables, clinical presentation, the date and time of onset of symptoms and the duration of symptoms, physician visits and hospitalizations were collected. Sixty viral outbreaks affecting 1791 people were identified, with no distinct seasonality. The mean number of outbreaks per month was 4.6. The global incidence was 24.6 per 100 000 person-years. The incidence was higher in women (25.7 per 100 000 person-years) and in the 5–11 years (52.4 per 100 000 person-years) and ≥65 years (42.4 per 100 000 person-years) age groups. The prevalence of vomiting, abdominal pain and general malaise was higher in children and adolescents, whereas the prevalence of diarrhoea and myalgia was higher in adults. These results suggest that norovirus infection has an important public health impact in Catalonia and that prevention strategies should be designed and implemented.

Three Klebsiella oxytoca isolates and one Klebsiella pneumoniae isolate from three children admitted to the Hematology Unit of Hospital Vall d'Hebron (Barcelona, Spain) exhibited a susceptibility pattern suggesting OXY β-lactamase hyperproduction. All the isolates contained a 95-kb plasmid that harbored bla OXY-1 , which was transferred by electrotransformation but could not be self-transferred by conjugation. A qnrS1 gene was also harbored in the bla OXY-1 -carrying plasmid. This is the first report of a plasmid-encoded OXY β-lactamase.

Fundamentos. La baja dosis infectiva y las múltiples vías de transmisión facilitan la presentación de brotes de norovirus. El objetivo fue comparar la incidencia de brotes por norovirus en hospitales y residencias en Cataluña. Métodos. Se realizó un estudio descriptivo de la serie de brotes de norovirus en el período del 15/10/2004 al 30/10/2005. Se rellenó una encuesta epidemiológica para cada brote. Las variables fueron: número de expuestos, enfermos, mecanismo de transmisión, ámbito (centros sanitarios o residencias), región sanitaria, mes del año, y duración. Mediante técnicas de PCR se investigó la presencia de norovirus en muestras clínicas. Se calculó la incidencia en cada centro y la incidencia anual de brotes por centros. Las diferencias se determinaron con la prueba de c2 y la t de Student con un grado de significación (p) inferior a 0,05. Resultados. Se detectaron 17 brotes, 6 en centros sanitarios y 11 en residencias. La tasa de ataque global fue del 33,4% (652/1951) y fue ligeramente superior en las residencias (35,2%) que en los centros sanitarios (31,4%). El 94,1% (16/17) de los brotes se produjeron por transmisión persona a persona y sólo el 5,9% (1/17) por alimentos. La media de días entre el primer y último caso del brote fue de 11,4 (DE = 6,9). La duración media de los síntomas fue de 2,39 días (SD=1,6) y también fue superior en los pacientes hospitalizados 2,63 (SD=1,7) en comparación a los pacientes de residencias 1,97 (SD=1,7) (p < 0,0001). Conclusiones. Norovirus es responsable de un número importante de brotes por transmisión persona a persona. Se debe protocolizar su control para reducir su número y su duración. Fundamentos. La baja dosis infectiva y las múltiples vías de transmisión facilitan la presentación de brotes de norovirus. El objetivo fue comparar la incidencia de brotes por norovirus en hospitales y residencias en Cataluña. Métodos. Se realizó un estudio descriptivo de la serie de brotes de norovirus en el período del 15/10/2004 al 30/10/2005. Se rellenó una encuesta epidemiológica para cada brote. Las variables fueron: número de expuestos, enfermos, mecanismo de transmisión, ámbito (centros sanitarios o residencias), región sanitaria, mes del año, y duración. Mediante técnicas de PCR se investigó la presencia de norovirus en muestras clínicas. Se calculó la incidencia en cada centro y la incidencia anual de brotes por centros. Las diferencias se determinaron con la prueba de c2 y la t de Student con un grado de significación (p) inferior a 0,05. Resultados. Se detectaron 17 brotes, 6 en centros sanitarios y 11 en residencias. La tasa de ataque global fue del 33,4% (652/1951) y fue ligeramente superior en las residencias (35,2%) que en los centros sanitarios (31,4%). El 94,1% (16/17) de los brotes se produjeron por transmisión persona a persona y sólo el 5,9% (1/17) por alimentos. La media de días entre el primer y último caso del brote fue de 11,4 (DE = 6,9). La duración media de los síntomas fue de 2,39 días (SD=1,6) y también fue superior en los pacientes hospitalizados 2,63 (SD=1,7) en comparación a los pacientes de residencias 1,97 (SD=1,7) (p < 0,0001). Conclusiones. Norovirus es responsable de un número importante de brotes por transmisión persona a persona. Se debe protocolizar su control para reducir su número y su duración.

Background Noroviruses (NoV) are highly contagious and the leading cause of nonbacterial outbreaks of gastroenteritis worldwide. Individuals who are infected asymptomatically may act as reservoirs and facilitate the transmission of NoV, but the likelihood of workers of becoming infected in outbreak settings has not been systematically studied. Objectives We evaluated the occurrence of norovirus infections among workers exposed to the virus in different outbreak settings. Study design We screened feces from food handlers and healthcare workers related with gastroenteritis outbreaks, and shedding concentrations over time were calculated from serial samples of infected individuals. Sequence analyses of the capsid P2 domain and region C were used to evaluate linkage between asymptomatic employees and outbreak cases. Results Of all employees, 59.1% were positive for NoV, and more than 70% of them were asymptomatic. Asymptomatic infections were significantly more frequent in foodborne compared to person-to-person transmitted outbreaks; and in restaurants and hotels, compared to nursing homes and healthcare institutions. Mean viral loads were similar between symptomatic and asymptomatic individuals, starting at 7.51 ± 1.80 and 6.49 ± 1.93 log10 genome copies/g, respectively, and decreasing to 5.28 ± 0.76 and 4.52 ± 1.45 log10 genome copies/g after 19 days. Conclusions The likelihood of becoming infected when a NoV outbreak occurs at the work place is high and similar between food handlers and healthcare workers, but asymptomatic infections are more frequently identified among food handlers. Since shed amounts of viruses in the absence of symptoms are also high, reinforcement of hygiene practices among workers is especially relevant to reduce the risk of virus secondary transmissions.

Staphylococcus aureus is a major cause of bacteremia in children and is associated with high morbidity. Complete data are lacking on the incidence, related risk factors and mortality associated with this infection.Descriptive study including patients younger than 16 years admitted to a tertiary reference hospital, with blood cultures exclusively positive for S. aureus. Four study periods were established: period 1, 1995-1999; period 2, 2000-2002; period 3, 2006-2008 and period 4, 2010-2012.In total, 269 episodes of S. aureus bacteremia (SAB) occurred in 242 patients. Over the total time studied, the incidence increased from 1.3 to 3.3 cases per 1000 patients hospitalized (relative risk: 2.71; 95% confidence interval: 1.85-3.95) and mortality decreased from 18% to 6% (P = 0.008). There were no differences in the resistance patterns of S. aureus strains. The prevalence of methicillin-resistant S. aureus (MRSA) increased from 3% to 13% between periods 1 and 2 and decreased from 14% to 3% between periods 3 and 4 (P = 0.011). The 30-day cumulative mortality was 3.3%, and the SAB-related mortality was 1.5%. Nosocomial acquisition and age 12-16 years were factors independently related with death on multivariate analysis.The incidence of SAB tripled during the years studied but remained stable in the last period. Antimicrobial resistances did not increase. Although a decrease in mortality was documented, approximately half the 30-day cumulative mortality was caused by SAB.

Objectives To evaluate the presence of qnr genes among enterobacterial isolates carrying extended-spectrum beta-lactamases (ESBLs) in Barcelona, Spain. Methods Screening for the qnrA, qnrB and qnrS genes was carried out by PCR amplification with specific primers in 305 non-duplicate, clinically relevant ESBL-producing enterobacterial isolates obtained from February 2003 to August 2004. ESBLs from all qnr-positive isolates were characterized by isoelectric focusing, PCR amplification and DNA sequencing. Plasmid analysis was performed by S1 digestion and hybridization with specific probes for the qnr and bla genes. Plasmids containing qnr genes were transferred by conjugation or transformation. The genetic environment of qnrA1 in selected isolates was characterized by cloning experiments. Results Fifteen isolates, each from a different individual, carried qnr. Among them, 14 had qnrA1 (6 Klebsiella pneumoniae, 6 Enterobacter cloacae and 2 Escherichia coli isolates) and 1 had qnrS1 (K. pneumoniae). None of the isolates carried qnrB. Among the qnrA1-carrying isolates, 10 possessed both bla(CTX-M-9) and bla(SHV-12), 2 had both bla(CTX-M-9) and bla(SHV-92) and 2 had bla(CTX-M-9) alone. The isolate with qnrS1 possessed bla(SHV-12). The qnrA1 and ESBL genes were located together on plasmids ranging in size from 40 to 320 kb. qnrS1 and bla(SHV-12) were not located on the same plasmid. Transfer of quinolone resistance was successfully achieved from all but three isolates. The cloned region surrounding qnrA in two K. pneumoniae isolates revealed a novel genetic organization. Conclusions The prevalence of qnr among enterobacterial clinical isolates carrying ESBLs between 2003 and 2004 in Barcelona was 4.9%. qnrA1 was the most prevalent, whereas only one qnrS and no qnrB were detected.

In most developed countries, nontyphoid Salmonella is an important cause of sporadic cases and outbreaks of foodborne gastroenteritis. The aim of this study was to investigate the trend of foodborne Salmonella-caused outbreaks and number of cases, hospitalizations, and deaths and compare them with those caused by other infectious agents. The study was carried out in Catalonia, a region in northeastern Spain with a population of 6.5 million inhabitants, in 2002. All information on reported outbreaks of foodborne disease from 1990 to 2003 was reviewed. For each outbreak, the following variables were collected: year; setting (household, restaurant, school, hospital, nursing home, and others); number of cases, hospitalizations, and deaths; causal agent; and food vehicle involved. Of 1652 reported outbreaks, 1078 had a known causal agent. Among them, 871 (80.8%) were caused by Salmonella, with 14,695 cases, 1534 hospitalizations, and 4 deaths. The rate of hospitalization was higher in outbreaks due to Salmonella than in those caused by other infectious agents (rate ratio, 2.54; 95% confidence interval, 2.20 to 2.94). Forty-eight percent of Salmonella-caused outbreaks were eggborne, compared with 5.3% of those caused by other infectious agents (rate ratio, 1.40; 95% confidence interval, 1.33 to 1.48). The annual number of cases in household outbreaks of eggborne Salmonella rose over time (R2 = 0.82), but the number of outbreaks produced in other settings did not. Eggborne outbreaks caused by Salmonella in households are a major cause of disease, and increased preventive efforts are necessary, especially consumer education and awareness of the risk of eating food containing raw or slightly cooked eggs.

Summary Background Most available information on carbapenemase-producing Enterobacteriaceae (CPE) is usually associated with specific types of infection or patient or with descriptions of outbreaks. The aim of this study was to comprehensively analyse the clinical epidemiology, clinical features and outcomes of colonisation and infections due to CPE in Spain. Methods A multicentre prospective cohort study was carried out in 34 Spanish hospitals from February to May 2013. All new patients testing positive for CPE in clinical samples were included. Logistic regression was used to identify predictors of mortality. Results Overall, 245 cases were included. The most frequent organism was Klebsiella pneumoniae (74%) and the carbapenemases belonged to the OXA-48 (74%), metallo-β-lactamase (MBL) (24%) and KPC (2%) groups. Acquisition was nosocomial in 145 cases (60%) and healthcare-associated (HCA) in 91 (37%); 42% of the latter were nursing home residents, in whom OXA-48-producing K. pneumoniae ST405 predominated. MBLs and OXA-48 predominated in ICU and medical patients, respectively. Overall, 67% of patients had infections. The most frequent infections identified in this study were urinary tract (43%) and skin structure (21%) infections, and 10% of infections were bacteraemic. Crude mortality was 20%. Inappropriate antibiotic therapy was independently associated with an increased risk of death (OR = 3.30; 95% CI: 1.34–8.11). Conclusions We found some differences in the epidemiology of CPE depending on the type of carbapenemase produced. Although a low proportion of CPE infections were bacteraemic, active antibiotic therapy was a protective factor for reducing mortality.

Fundamento y objetivo Investigar un brote de gastroenteritis que afecto a los trabajadores y residentes (con diferentes grados de dependencia) de una residencia asistida. Pacientes y metodo El 25 de octubre de 2004 se detecto un brote en una residencia de Oliana (Lleida) con 52 trabajadores y 124 residentes. Se realizo un estudio de cohortes bidireccional, retrospectivo y prospectivo sobre el consumo de agua, alimentos, grado de dependencia y tipo de trabajo. Se tomaron muestras de agua y de 6 alimentos. Mediante la tecnica de reaccion en cadena de la polimerasa se determino la presencia del ADN de Norovirus en heces de 30 pacientes. La implicacion de cada factor se estudio con el riesgo relativo (RR) y su intervalo de confianza (IC) del 95%. Resultados Se entrevisto al 97,7% de los expuestos (172/176). La tasa de ataque global fue del 53,3% (92/172). La proporcion de sintomas fue la siguiente: diarrea en un 68,5% (63/92), vomitos en un 64,1% (59/92), nauseas en un 63% (58/92), fiebre en un 33,7% (31/92), dolor abdominal en un 28,3% (26/92) y cefalea en un 14,1% (13/92). La curva epidemica indico transmision durante 19 dias. Los factores asociados al riesgo de enfermar fueron: grados de dependencia alto (RR = 1,6; IC del 95%, 1,0-2,6) y medio (RR = 1,7; IC del 95%, 1,0-2,7), el mayor contacto de los trabajadores con los residentes (RR = 2,8; IC del 95%, 1,1-7,3) y realizar tareas de limpieza (RR = 2,8; IC del 95%, 1,0-8,0). Doce muestras de heces resultaron positivas a Norovirus. Los analisis de la muestra de agua y de los 6 alimentos fueron negativos. Conclusiones Se constato en una residencia asistida la existencia de un brote de Norovirus de transmision persona a persona, asociado al grado de dependencia de los residentes, al mayor contacto de los trabajadores con aquellos y a la realizacion de tareas de limpieza.

Resistance to β-lactams and quinolones in two isogenicEnterobacter cloacaeisolates was studied. One was susceptible to cefoxitin and amoxicillin-clavulanate. The other one showed its natural β-lactam resistance pattern. Both isolates had a nonfunctional AmpR regulator. However, within the second one, the presence of a plasmid carryingampRandqnrA1allowed reversion to the wild-type β-lactam resistance phenotype and decreased susceptibility to fluoroquinolones.

Fundamento y objetivo: Se ha investigado un brote de toxiinfeccion alimentaria que afecto a los clientes de un hotel y en el que la epidemiologia analitica y el analisis microbiologico permitieron determinar que el agente etiologico fue Norovirus y la fuente de infeccion, los manipuladores de alimentos. Pacientes y metodo: El dia 26 de junio de 2002 se detecto un brote de gastroenteritis que afectaba a un grupo de 59 alumnos y profesores de un colegio alojados en un hotel de Espot (Lleida). Se realizo un estudio de cohortes historicas sobre la exposicion a aguas y alimentos y sintomas clinicos. Se estudiaron el sistema de suministro y distribucion del agua de la red municipal y los menus consumidos. La investigacion microbiologica consistio en el coprocultivo y la determinacion de Norovirus en heces de 14 enfermos y de 4 manipuladores. La implicacion de cada alimento se estudio mediante el riesgo relativo (RR) y el intervalo de confianza del 95%. Resultados: Se entrevisto al 96,6% de los expuestos (57/59). La tasa de ataque global fue del 66,7% (38/57). La mediana del periodo de incubacion fue de 25,0 h (maximo de 51 y minimo de 19 h). La proporcion de sintomas fue: dolor abdominal en el 94,7% (36/38), vomitos en el 86,8% (33/38), nauseas en el 76,3% (29/38), diarrea en el 52,6% (20/38) y fiebre en el 48,6% (17/35). De los 4 tipos de agua y de los 13 alimentos estudiados, el unico que resulto implicado fue el consumo de bocadillos (riesgo relativo = 2,3; intervalo de confianza del 95%, 1,1-5,1). Los coprocultivos fueron negativos. En el analisis por reaccion en cadena de la polimerasa, 12 de las 14 muestras de heces de enfermos resultaron positivas a Norovirus. Tambien se obtuvo un resultado positivo al mismo virus en 2 de los 4 manipuladores. Ninguno de ellos habia presentado sintomas clinicos. Conclusiones: Los manipuladores deben ser investigados sistematicamente en los brotes por Norovirus y ademas deben cumplir de forma estricta las recomendaciones higienicas, especialmente en la preparacion de alimentos de consumo en crudo.

Phage typing and DNA macrorestriction fragment analysis by pulsed-field electrophoresis (PFGE) were used for the epidemiological subtyping of a collection of Shiga toxin-producing Escherichia coli (STEC) O157:H7 strains isolated in Spain between 1980 and 1999. Phage typing distinguished a total of 18 phage types among 171 strains isolated from different sources (67 humans, 82 bovines, 12 ovines, and 10 beef products). However, five phage types, phage type 2 (PT2; 42 strains), PT8 (33 strains), PT14 (14 strains), PT21/28 (11 strains), and PT54 (16 strains), accounted for 68% of the study isolates. PT2 and PT8 were the most frequently found among strains from both humans (51%) and bovines (46%). Interestingly, we detected a significant association between PT2 and PT14 and the presence of acute pathologies. A group of 108 of the 171 strains were analyzed by PFGE, and 53 distinct XbaI macrorestriction patterns were identified, with 38 strains exhibiting unique PFGE patterns. In contrast, phage typing identified 15 different phage types. A total of 66 phage type-PFGE subtype combinations were identified among the 108 strains. PFGE subtyping differentiated between unrelated strains that exhibited the same phage type. The most common phage type-PFGE pattern combinations were PT2-PFGE type 1 (1 human and 11 bovine strains), PT8-PFGE type 8 (2 human, 6 bovine, and 1 beef product strains), PT2-PFGE subtype 4A (1 human, 3 bovine, and 1 beef product strains). Nine (29%) of 31 human strains showed phage type-PFGE pattern combinations that were detected among the bovine strains included in this study, and 26 (38%) of 68 bovine strains produced phage type-PFGE pattern combinations observed among human strains included in this study, confirming that cattle are a major reservoir of strains pathogenic for humans. PT2 and PT8 strains formed two groups which differed from each other in their motilities, stx genotypes, PFGE patterns, and the severity of the illnesses that they caused.

Introduction In neonatal units, Salmonella infections have been attributed to food-borne sources and person to person transmission. Methods The outbreak described is the first reported by Salmonella enterica serotype Newport in a neonatal facility in Spain. Results The index case was an 8-day premature newborn that developed clinical sepsis with positive blood cultures. The outbreak source was the mother of the index case. Conclusions It is essential to improve infection control measures taking into account the parents, as they can be an important source of infection.

SUMMARYA descriptive study was performed between 1 January 2010 and 31 December 2011 to estimate the incidence of norovirus outbreaks in hospitals and nursing homes in Catalonia (Spain). Epidemiological surveys were done for each outbreak. Norovirus was confirmed using RT–PCR. The incidence of outbreaks/106 person-years by centre, and the attack rate, were calculated. Statistically significant differences were calculated using odds ratio (ORs) and 95% confidence intervals (CIs). Person-to-person transmission was responsible for 81·5% (22/27) of outbreaks. The incidence in the population was 156·7 outbreaks/106 person-years. The incidence by centre was 1·3% per year and was greater in hospitals (2·6%) than in nursing homes (0·9%) (OR 3·2, 95% CI 1·5–6·9). The global attack rate in residents and staff was 34·7% (816/2348). The mortality rate was 0·25% (2/816). Genogroup GII.4 caused 66·7% of outbreaks. Norovirus GII.4 outbreaks cause significant morbidity affecting both patients and staff.

Fundamento Esclarecer el papel protector de Lactobacillus frente a la vulvovaginitis candidiasica. Pacientes y metodo Estudio in vitro que determina la capacidad de 15 cepas de Lactobacillus de bloquear la adhesion de dos cepas de Candida albicans y una de C. glabrata a las celulas epiteliales vaginales, asi como la capacidad de inhibir el crecimiento de estas levaduras. Ademas se ha determinado la presencia de Lactobacillus en 115 exudados vaginales de mujeres con vulvovaginitis candidiasica. Resultados Solo 8 de los 15 Lactobacillus bloquearon significativamente la adhesion de C. albicans Y18 a las celulas vaginales. Lactobacillus del grupo hemaglutinante III presentaron la mayor capacidad de bloqueo (62,9%), seguidos de los grupos II (50,6%) y I (26,1%). Ninguno de los 15 Lactobacillus estudiados fue capaz de inhibir en medio solido el crecimiento de las tres levaduras; sin embargo, en medio liquido algunos Lactobacillus evidenciaron cierto poder inhibidor frente a C. albicans Y17 (35,7, 41,7 y 38,1% de transmitancia para los Lactobacillus de los grupos I, II y III, respectivamente). Se detecto la presencia de Lactobacillus en el 89,6% de las mujeres con vulvovaginitis candidiasica, en el 87,8% mediante visualizacion microscopica y en el 72,2% mediante cultivo. Conclusion Los resultados de este estudio sugieren que probablemente Lactobacillus ejerce proteccion contra la vulvovaginitis candidiasica.

Introduction: The aim of this study was to describe the investigation of a case of meningitis in a neonatal intensive care unit in order to identify the source of infection and the associated risk factors. Material and methods: An analysis was carried out on the possible risk factors associated with the infection. E. sakazakii was detected in the batch of the powdered infant formula used during the feeding of the neonate and the initial level of contamination of the microorganism was estimated. The strains of E. sakazakii previously isolated in blood and faeces of the infected neonate and those isolated in infant formula were characterised by biotype, pulsotype and antimicrobial susceptibility. Results: E. sakazakii was detected in one opened and two unopened cases of a single batch of powdered infant formula. The E. sakazakii strains isolated in the samples of the product and those isolated in the infected neonate showed the same biochemical, antibiotic susceptibility and PFGE pattern. Conclusions: The case of meningitis in the neonatal intensive care unit occurred as a result of the use of a powered infant formula contaminated with E. sakazakii at manufacturing level, and an inadequate preparation and storing of the reconstituted product were identified as risk factors.

From 1979 to 1996, 58 patients (mean age, 39.4 years) were treated for bacteremia due to Campylobacter species at the Hospitals Vall d'Hebron in Barcelona, Spain. Bacteremia was considered to be hospital acquired in 30% of these patients. Almost all the patients (93%) had underlying conditions; liver cirrhosis was the most frequent (34% of patients), and neoplasia, immunosuppressive therapy, and human immunodeficiency virus disease were also common. Of the 58 Campylobacter strains isolated, 81% were C. jejuni, 10% were Campylobacter species, 7% were C. fetus, and one (2%) was C. coli. Resistance rates were: cephalothin, 82%; co-trimoxazole, 79%; quinolones, 54%; ampicillin, 20%; amoxicillin/clavulanate, 4%; erythromycin, 7%; gentamicin, 0; and tetracyclines, 0. Even though the majority of patients were immunocompromised, mortality was low (10.5%), and only one patient relapsed. Because of the high level of resistance to the quinolones in Campylobacter species, these drugs should not be used as empirical treatment, at least in Spain. Although the macrolides remain the antibiotics of choice, amoxicillin/clavulanate may be an effective alternative therapy.

Background Norovirus (NoV) is the most common cause of acute nonbacterial gastroenteritis outbreaks worldwide, but the impact of NoV infections in Spain remains underestimated. Objectives This study aimed to determine the prevalence and genetic diversity of NoVs causing outbreaks of acute gastroenteritis in Northeastern Spain (Catalonia) during 2010–2012, and to compare clinical features and levels of viral shedding of the most prevalent GII.4 2012 variant with its predecessor. Study design NoVs were screened and genotyped in stools from gastroenteritis outbreaks. Genetic diversity over a region covering 50% of VP1, and viral loads were analyzed in stools belonging to GII.4 2009 and 2012 variants. Results More than 50% of outbreaks were caused by genotype GII.4, although outbreaks caused by multiple strains, GII.6 and GII.1 were also prevalent. During 2012, GII.4 2012 strains clearly replaced GII.4 2009 strains. The first 2012 strain was detected in February 2011, representing the earliest isolate reported worldwide. Epidemiological features of GII.4 2012 and GII.4 2009 outbreaks were comparable, as well as levels of viral shedding in stools. Finally, analysis of the capsid gene showed a higher amino acid variability and diversification in GII.4 2012, affecting sites located at the P2 domain, but also in the shell domain. Conclusions Clinical features of outbreaks caused by different genotypes circulating in Spain, including outbreaks caused by GII.4 2012 and GII.4 2009 strains, were comparable. Although shed at similar levels than GII.4 2009 strains, GII.4 2012 strains have clearly replaced the previous predominant strain.

We conducted a prospective multicenter study in Spain to characterize the mechanisms of resistance to amoxicillin-clavulanate (AMC) in Escherichia coli . Up to 44 AMC-resistant E. coli isolates (MIC ≥ 32/16 μg/ml) were collected at each of the seven participant hospitals. Resistance mechanisms were characterized by PCR and sequencing. Molecular epidemiology was studied by pulsed-field gel electrophoresis (PFGE) and by multilocus sequence typing. Overall AMC resistance was 9.3%. The resistance mechanisms detected in the 257 AMC-resistant isolates were OXA-1 production (26.1%), hyperproduction of penicillinase (22.6%), production of plasmidic AmpC (19.5%), hyperproduction of chromosomic AmpC (18.3%), and production of inhibitor-resistant TEM (IRT) (17.5%). The IRTs identified were TEM-40 (33.3%), TEM-30 (28.9%), TEM-33 (11.1%), TEM-32 (4.4%), TEM-34 (4.4%), TEM-35 (2.2%), TEM-54 (2.2%), TEM-76 (2.2%), TEM-79 (2.2%), and the new TEM-185 (8.8%). By PFGE, a high degree of genetic diversity was observed although two well-defined clusters were detected in the OXA-1-producing isolates: the C1 cluster consisting of 19 phylogroup A/sequence type 88 [ST88] isolates and the C2 cluster consisting of 19 phylogroup B2/ST131 isolates (16 of them producing CTX-M-15). Each of the clusters was detected in six different hospitals. In total, 21.8% of the isolates were serotype O25b/phylogroup B2 (O25b/B2). AMC resistance in E. coli is widespread in Spain at the hospital and community levels. A high prevalence of OXA-1 was found. Although resistant isolates were genetically diverse, clonality was linked to OXA-1-producing isolates of the STs 88 and 131. Dissemination of IRTs was frequent, and the epidemic O25b/B2/ST131 clone carried many different mechanisms of AMC resistance.

Introduction Campylobacter outbreaks are less common and described than sporadic Campylobacteriosis. Methods We describe the epidemiological investigation including stool examination and bacteriological typing of a Campylobacter outbreak affecting 75 primary school children. Results The highest risk ratio was associated with the food served 4 days before the peak of cases, namely roast chicken and Russian salad. Discussion Poor food preparation practices and deficient kitchen facilities appear to be key issues for cross-contamination of Campylobacter from raw chicken to cooked food.

1. Jacoby GA, Gacharna N, Black TA et al. Temporal appearance of plasmid-mediated quinolone resistance genes. Antimicrob Agents Chemother 2009; 53: 1665–6. 2. Robicsek A, Jacoby GA, Hooper DC. The worldwide emergence of plasmid-mediated quinolone resistance. Lancet Infect Dis 2006; 6: 629–40. 3. Torpdahl M, Hammerum AM, Zachariasen C et al. Detection of qnr genes in Salmonella isolated from humans in Denmark. J Antimicrob Chemother 2009; 63: 406–8. 4. Fang H, Huang H, Shi Y et al. Prevalence of qnr determinants among extended-spectrum b-lactamase-positive Enterobacteriaceae clinical isolates in southern Stockholm, Sweden. Int J Antimicrob Agents 2009; 34: 268–70. 5. Pallecchi L, Riccobono E, Mantella A et al. High prevalence of qnr genes in commensal enterobacteria from healthy children in Peru and Bolivia. Antimicrob Agents Chemother 2009; 53: 2632–5. 6. Osterblad M, Hakanen A, Manninen R et al. A between-species comparison of antimicrobial resistance in enterobacteria in fecal flora. Antimicrob Agents Chemother 2000; 44: 1479–84. 7. Osterblad M, Pensala O, Peterzens M et al. Antimicrobial susceptibility of Enterobacteriaceae isolated from vegetables. J Antimicrob Chemother 1999; 43: 503–9. 8. Robicsek A, Strahilevitz J, Sahm DF et al. qnr prevalence in ceftazidime-resistant Enterobacteriaceae isolates from the United States. Antimicrob Agents Chemother 2006; 50: 2872–4. 9. qnr Numbering and Sequence. http://www.lahey.org/qnrStudies (27 July 2009, date last accessed.) 10. Kehrenberg C, Friedrichs S, De Jong A et al. Novel variant of the qnrB gene, qnrB12, in Citrobacter werkmanii. Antimicrob Agents Chemother 2008; 52: 1206–7.

SUMMARYVibrio parahaemolyticus and Norovirus have been recognized as the cause of sporadic cases or outbreaks of diarrhoeal illness in association with the ingestion of raw or improperly cooked seafood. This report describes a foodborne outbreak of gastroenteritis caused by both Norovirus and Vibrio parahaemolyticus following the consumption of raw seafood in a restaurant in Terrassa (Catalonia, Spain) in September 2005. Measures are needed to reduce contamination of raw seafood. Consumers can reduce the risk of foodborne illness by avoiding consumption of raw or undercooked food.

Noroviruses are the most common cause of outbreaks of viral gastroenteritis worldwide. Norovirus outbreaks were surveyed in Catalonia and the region of Valencia (Eastern Spain) between January 2001 and December 2006 as part of the European Union funded network "Food-borne viruses in Europe". During this time the etiology and epidemiological features of 194 outbreaks of acute non-bacterial gastroenteritis were investigated and norovirus was identified as causing 169 (87.1%) of them. Molecular epidemiology of viral strains was studied by RT-PCR and sequencing part of the RNA polymerase gene in ORF1 from 153 outbreak strains. The most commonly identified norovirus genotype was GII.4 (71.9% of the characterized outbreak strains), which is also the predominant genotype worldwide. During this survey five genetic variants of GII.4 genotype have been sequentially detected and identified as 1996, 2002, 2004, 2006a, and 2006b variants. The transition from one variant to a new one always took place over a short period of time, and thereafter the replacement of strains circulating previously was observed. These new GII.4 variants may have arisen as a consequence of viral evasion from the host immune responses, although apparently there is a lack of long-term immunity after norovirus infections.

Objective. To describe the epidemiology of norovirus (NV) and Salmonella gastroenteritis outbreaks in Catalonia between 15 October 2004 and 30 October 2005. Material and methods. Epidemiological data were obtained from outbreak reports. The aetiologic agent was investigated by culture for enteric bacteria, enzyme immunoanalyses, reverse transcription polymerase chain reaction (RT-PCR) and molecular epidemiology genotyping for NV. The x 2 test was used to compare proportions. Incidence rates and their confidence intervals (CI) were calculated assuming a Poisson distribution. Results. A total of 225 acute gastroenteritis (AG) outbreaks were reported, with 3436 persons affected and 115 hospitalized. Sixty outbreaks (27%) accounting for 1791 cases (52%) were caused by NV, with an attack rate (AR) of 34.7% and a hospitalization rate (HR) of 0.2%. Seventy- four outbreaks (33%) were caused by Salmonella spp., affecting 646 persons (18.8% (AR 45.6% and HR 13.7%)). The difference in AR between Salmonella spp. and NV was statistically significant (odds ratio (OR) 1.57; 95% CI: 1.391.78; p B0.001). The median number of affected persons per outbreak was 3-fold higher for NV (15 (2174)) than for Salmonella (5 (244)). The incidence rate of AG cases associated with NVoutbreaks was significantly higher (24.9 per 100,000 persons/year (95% CI: 23.726.1)) than for those associated with Salmonella (5 (244)) outbreaks (9.2 per 100,000 persons/year (95% CI: 8.59.9)). Conclusions. The disease burden and impact of NV highlight the importance of timely notification and investigation of outbreaks and the development and implementation of preventive measures, such as health and safety education for caregivers and food handlers in order to reduce the incidence of infections.

Background Acute infectious gastroenteritis causes substantial morbidity and economic loss. Objective The aetiology, epidemiology, and clinical features of acute viral gastroenteritis outbreaks reported during 1 year in Catalonia were investigated. Study Design This was a population-based study in which enzyme immunoassay and reverse transcriptase-polymerase chain reaction (RT-PCR) techniques were used to determine the presence of virus in stool specimens from outbreaks clinically and epidemiologically compatible with a viral aetiology and negative for bacteria, parasites and toxins. Results Sixty outbreaks affecting 1791 people were evaluated. Fifty-five outbreaks were positive for norovirus, four were positive for norovirus and other microorganisms (adenovirus, astrovirus, S. Typhimurium and V. parahaemolyticus in one each). Thirty-seven percentage of the outbreaks occurred in collective catering; 18.3% in nursing homes; 10% in hospitals and long-term-care facilities. Foodborne transmission accounted for 50% of outbreaks. Norovirus genotype GGII.4 accounted for 42% of all the outbreaks, being more prevalent in nursing homes, hospital and long-term-care facilities. Conclusions The large number of norovirus outbreaks and resulting health service demand and absenteeism indicate that acute gastroenteritis caused by norovirus is an important health problem in Catalonia. Preventive measures should target education and control of food handlers, and immediate specific control measures should be adopted in institutions.

In August 2002 an outbreak of Shigella sonnei infection occurred in a Spanish town of 6343 inhabitants. In total, 756 people developed acute gastroenteritis and 181 cases were shigella-confirmed. The peak incidence was during 5–6 August 2002. The estimated primary attack rate was 9·97%; the attack rate for secondary cases was 38%. The

To gain insight into the mechanisms by which Lactobacillus blocks the adherence of uropathogens to vaginal epithelial cells and inhibits their growth, 15 Lactobacillus strains and 22 uropathogens were studied. Lactobacilli from hemagglutination group III, identified as Lactobacillus crispatus, showed greater capacity to block uropathogen adherence than those from hemagglutination groups II and I (61.9%, 49.5%, and 52.6% of blockage, respectively). Pseudomonas aeruginosa PA5 and Klebsiella pneumoniae KP7 were the uropathogens most susceptible to blockage, and Staphylococcus aureus SA11 and Proteus mirabilis PM1 were the most resistant. Lactobacillus inhibited uropathogen growth better in liquid assays; the 3 Lactobacillus groups showed similar inhibitory power (72.3%, 71.9%, and 74.2% of light transmittance). P. aeruginosa PA5 was the most inhibited, and Enterococcus species E15 was the least inhibited. There is considerable variation among Lactobacillus strains regarding their adherence to uroepithelium, blockage of uropathogen attachment, and inhibition of uropathogen growth. Although these properties are independent, they may coincide and therefore allow for these strains to balance the vaginal ecosystem and to make them useful as probiotics.

Background: To determine the direct and indirect costs of outbreaks of acute viral gastroenteritis (AVG) due to norovirus in closed institutions (hospitals, social health centers or nursing homes) and the community in Catalonia in 2010–11. Methods: Information on outbreaks were gathered from the reports made by epidemiological surveillance units. Direct costs (medical visits, hospital stays, drug treatment, sample processing, transport, diagnostic tests, monitoring and control of the outbreaks investigated) and indirect costs (lost productivity due to work absenteeism, caregivers time and working hours lost due to medical visits) were calculated. Results: Twenty-seven outbreaks affecting 816 people in closed institutions and 74 outbreaks affecting 1,940 people in the community were detected. The direct and indirect costs of outbreaks were € 131,997.36 (€ 4,888.79 per outbreak) in closed institutions and € 260,557.16 (€ 3,521.04 per outbreak) in community outbreaks. The cost per case was € 161.76 in outbreaks in closed institutions and € 134.31 in community outbreaks. The main costs were surveillance unit monitoring (€ 116,652.93), laboratory diagnoses (€ 119,950.95), transport of samples (€ 69,970.90), medical visits (€ 25,250.50) and hospitalization (€ 13,400.00). Conclusions: The cost of outbreaks of acute viral gastroenteritis due to norovirus obtained in this study was influenced by the number of people affected and the severity of the outbreak, which determined hospitalizations and work absenteeism. Urgent reporting of outbreaks would allow the implementation of control measures that could reduce the numbers affected and the duration of the illness and thus the costs derived from them. This work was supported by the National Plan of I+D+I 2008-2011 and ISCIII-Subdirección General de Evaluación y Fomento de la Investigación [Project PI12/02079] and cofounded by FEDER, and the Catalan Agency for the Management of Grants for University Research [AGAUR Grant number 2014/ SGR 1403].

Therapy for recurrent Clostridium difficile-associated diarrhea (CDAD) is challenging. We evaluated the frequency, associated risk factors, and prognosis of first CDAD recurrences. Prospective cohort study of all consecutive cases of primary CDAD diagnosed in a university hospital from January 2006 to June 2013. Recurrent infection was defined as reappearance of symptoms within 8 weeks of the primary diagnosis, provided that CDAD symptoms had previously resolved and a new toxin test was positive. Predictors of a first episode of recurrent CDAD were determined by logistic regression analysis. In total, 502 patients (51.6 % men) with a mean age of 62.3 years (SD 18.5) had CDAD; 379 (76 %) were cured, 61 (12 %) had a first recurrence, 52 (10 %) died within 30 days of the CDAD diagnosis, nine (2 %) required colectomy, and one was lost to follow-up. Among the 61 patients with a first recurrence, 36 (59.3 %) were cured, 15 (23.7 %) had a second recurrence, nine (15.3 %) died, and one (1.7 %) required colectomy. On multivariate analysis, age older than 65 years (OR 2.04; 95 % CI, 1.14-3.68; P