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As a follow-up to a previous study, we investigated vaccine effectiveness (VE) of 23-valent pneumococcal polysaccharide vaccine (PPSV23) against invasive pneumococcal disease (IPD) among 1,254,498 persons >65 years of age as part of a vaccination program in Denmark during April 2020-January 2023. We assessed VE by using a Cox regression model and adjusted for age, sex, and underlying conditions. Using nationwide data, we estimated a VE of PPSV23 against all-type IPD of 32% and against PPSV23-serotype IPD of 41%. Because this follow-up study had more statistical power than the original study, we also estimated VE against IPD caused by PPSV23-serotypes excluding serotype 3; serotype 3; serotype 8; serotype 22F; PPSV23 non-PCV15 serotypes; PPSV23 non-PCV20 serotypes; and IPD over time. Our findings suggest PPSV23 vaccination can protect persons >65 years of age against IPD caused by all serotypes or serotype groupings, except serotype 3.

This study aimed to estimate the effectiveness of the 23-valent pneumococcal polysaccharide vaccine (PPV23) against invasive pneumococcal disease (IPD) among individuals ≥ 65 years of age. We used Danish nationwide databases to obtain information on PPV23 vaccination, covariates, and IPD and linked data on an individual level using a unique personal identifier. A total of 948,263 individuals were included and followed between June 15, 2020, and September 18, 2021 (58.6% were vaccinated during follow-up). The adjusted vaccine effectiveness was 42% (95% confidence interval (CI): 9-63%) for all-serotype IPD and 58% (95% CI: 21-78%) for PPV23-serotype IPD, using no vaccination as the reference., (© 2022. The Author(s).)

Background: Streptococcus pneumoniae serotype 8 incidence has increased in Denmark after the introduction of pneumococcal conjugated vaccines (PCV). The mechanism behind the serotype 8 replacement is not well understood. In this study, we aimed to present epidemiological data on invasive pneumococcal disease (IPD) and molecular characterization of 96 serotype 8 clinical isolates., Methods: IPD data from 1999 to 2019 were used to calculate the incidence and age distribution. Whole-genome sequencing (WGS) analysis was performed on 96 isolates (6.8% of the total serotype 8 IPD isolates in the period) to characterize the isolates with respect to pneumococcal lineage traits, a range of genes with potential species discrimination, presence of colonization and virulence factors, and molecular resistance pattern., Results: The serotype 8 IPD incidence increased significantly (P < 0.05) for the age groups above 15 years after the introduction of PCV13, primarily affecting the elderly (65+). All isolates were phenotypically susceptible to penicillin, erythromycin and clindamycin. Molecular characterization revealed seven different MLST profiles with ST53 as the most prevalent lineage (87.5%) among the analyzed serotype 8 isolates. The genes covering the cell-surface proteins: lytA, rspB, pspA, psaA & Xisco and the pneumococcal toxin pneumolysin = ply were present in all isolates, while genes for the membrane transporter proteins: piaA/piaB/piaC; the capsular genes: cpsA (wzg) & psrP; the metallo-binding proteins zmpB & zmpC; and the neuroamidase proteins: nanA/nanB were variably present. Surprisingly, the putative transcriptional regulator gene SP2020 was not present in all isolates (98%). Susceptibility to penicillin, erythromycin and clindamycin was molecularly confirmed., Conclusion: The observed serotype 8 replacement was not significantly reflected with a change in the MLST profile or changes in antibiotic resistance- or virulence determinants.

The number of invasive Streptococcus agalactiae (GBS) non-typeable (NT) isolates in Denmark received since 1999 has in general accounted for 10% of all invasive GBS isolates. We present data on 55 clinical NT isolates based on clinical manifestations, clonal relationship, antimicrobial resistance (AMR) determinants, and virulence factors. The GBS isolates included in this study were phenotypic-based NT obtained from 2015 to 2017, as well as 10 reference isolates. Whole genome sequencing (WGS) was performed on all isolates and the data were analyzed for the presence of both species specific genes, capsular genes (genotype), and other relevant genes. We furthermore compared different procedures for detection of serotype specific capsular genes. Overall we were able to genotype 54 of the 55 isolates. After retesting the isolates a phenotype was detected for 20 (36%) isolates, of which the initial phenotyping problem for 13 isolates was found to be due to a problem with serotype Ia specific antiserum. Thirty-five isolates remained phenotypic non-typeable with a majority of genotype V isolates which do not express a capsular gene. From all the Danish invasive GBS isolates from 2015 to 2017, the 35 NT isolates were all detected in the age group above 21 years with bacteremia. The 35 NT isolates belonged to six different well-known human pathogenic clonal complexes. The CDC recommended sequences for capsule genotyping were the most optimal for serotype prediction, because of the sequence simplicity and clear cutoff values. However we recommend to also use other capsular sequences for the NT isolates, if they cannot be genotyped by the CDC method., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Slotved, Fuursted, Kavalari and Hoffmann.)

Introduction: By end of 2018, the European Union countries hosted approximately 2.5 million refugees and Lebanon alone hosted more than 1 million. The majority of refugees worldwide came from Syria. The prevailing study design in published studies on asylum seekers' and refugees' health leaves a number of fundamental research questions unanswerable. In the Asylum seekers' and Refugees' Changing Health (ARCH) study, we examine the health of a homogeneous group of refugees and asylum seekers in two very different host countries with very different migration histories. We aim to study the health impact of the migration process, living conditions, access to healthcare, gene-environment interactions and the health transition., Methods and Analysis: ARCH is an international multisite study of the health of adult (>18 years old) Syrian refugees and asylum seekers in Lebanon and Denmark. Using a standardised framework, we collect information on mental and physical health using validated scales and biological samples. We aim to include 220 participants in Danish asylum centres and 1100 participants in Lebanese refugee camps and settlements. We will use propensity score weights to control for confounding and multiple imputation to handle missing data., Ethics and Dissemination: Ethical approval has been obtained in Lebanon and Denmark. In the short term, we will present the cross-sectional association between long-distance migration and the results of the throat and wound swab, blood and faeces samples and mental health screenings. In the longer term, we are planning to follow the refugees in Denmark with collection of dried blood spots, mental health screenings and semistructured qualitative interviews on the participant's health and access to healthcare in the time lived in Denmark. Here, we present an overview of the background for the ARCH study as well as a thorough description of the methodology., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The taxonomic status of all Pseudocitrobacter species was re-evaluated by comparative genomics based on whole genome sequencing. As a result, it is obvious that Pseudocitrobacter anthropi is a later heterotypic synonym of Pseudocitrobacter faecalis . In addition, genome-based analysis of strain CPO20170097 T , isolated from a patient in northern Denmark was allocated to the genus Pseudocitrobacter . This strain showed significant genotypic and phenotypic differences from P. faecalis and it is proposed that this strain represents a novel species of the genus, for which the name Pseudocitrobacter vendiensis sp. nov. is proposed with the type strain CPO20170097 T (=CCUG 73096 T =LMG 31042 T ).

Background: Systemic inflammation following curative surgery for colorectal cancer may be associated with increased risk of recurrence. [Correction added on 29 November 2019, after first online publication: text amended for accuracy.] This study investigated whether a clinically suspected infection, for which blood cultures were sent within 30 days after surgery for colorectal cancer, was associated with long-term oncological outcomes., Methods: This register-based national cohort study included all Danish residents undergoing surgery with curative intent for colorectal cancer between January 2003 and December 2013. Patients who developed recurrence or died within 180 days after surgery were not included. Associations between blood cultures taken within 30 days after primary surgery and overall survival, disease-free survival and recurrence-free survival were analysed using Cox regression models adjusted for relevant clinical confounders, including demographic data, cancer stage, co-morbidity, blood transfusion, postoperative complications and adjuvant chemotherapy., Results: The study included 21 349 patients, of whom 3390 (15·9 per cent) had blood cultures taken within 30 days after surgery. Median follow-up was 5·6 years. Patients who had blood cultures taken had an increased risk of all-cause mortality (hazard ratio (HR) 1·27, 95 per cent c.i. 1·20 to 1·35; P < 0·001), poorer disease-free survival (HR 1·22, 1·16 to 1·29; P < 0·001) and higher risk of recurrence (HR 1·15, 1·07 to 1·23; P < 0·001) than patients who did not have blood cultures taken., Conclusion: A clinically suspected infection requiring blood cultures within 30 days of surgery for colorectal cancer was associated with poorer oncological outcomes., (© 2019 BJS Society Ltd Published by John Wiley & Sons Ltd.)

In 2008-2009 a tick-borne encephalitis virus (TBEV) micro-focus was detected in Northern Zealand, Denmark. No new cases of TBE with an epidemiological link to Northern Zealand has been reported since. Here we undertook to investigate Ixodes ricinus ticks from this endemic micro-focus in 2016 and 2017. In addition to TBEV, I. ricinus ticks may host other pathogens that include Borrelia spp., Babesia spp., Rickettsia spp. and Neoehrlichia mikurensis, together with various endosymbiont microorganisms. To detect multiple organisms we used a metagenomics PanVirus microarray and next-generation sequencing to examine the persistence and evolution of other emerging viruses, bacteria and parasites. Here we report the rise and fall of the Danish TBEV micro-focus in Northern Zealand. However, we identify for the first time in Danish I. ricinus ticks the presence of Uukuniemi virus in addition to a tick-borne phlebovirus and a range of bacteria., (Copyright © 2019 Elsevier GmbH. All rights reserved.)

Since 2012, have we in Denmark observed an increase of invasive pneumococcal infections (IPD) due to Streptococcus pneumoniae serotype 24F. We here present epidemiological data on 24F IPD cases, and characterization of 48 24F clinical isolates based on clonal relationship, antimicrobial resistance (AMR) determinants and virulence factors. IPD surveillance data from (1999-2016) were used to calculate the incidence and age-distribution of serotype 24F IPD and the effect of pneumococcal conjugated vaccines (PCV). Characterization of forty-eight 24F isolates (14.7% of all 24F isolates from the period) was based on whole-genome sequencing analysis (WGS). The IPD cases of serotype 24F showed a significant increase (p < 0.05) for all age groups after the PCV-13 introduction in 2010. The majority of tested 24F isolates consisted of two MLST types, i.e. the ST72 and the ST162. Serotype 24F IPD increased in Denmark after the PCV-13 introduction in parallel with an increase of the ST162 clone. The genotypic penicillin binding protein (PBP) profile agreed with the phenotypical penicillin susceptibility. The virulence genes lytA, ply, piaA, piaB, piaC, rspB and the cpsA/wzg were detected in all 24F isolates, while the pspA and zmpC genes were absent.

This study examined the carriage of Streptococcus pneumoniae in healthy Danish children aged 8-19 months and assessed the effect of the probiotics Lactobacillus rhamnosus GG and Bifidobacterium animalis subsp lactis on the pneumococcal carriage during daycare enrolment. Potential risk factors of pneumococcal carriage were analysed and the carriage study was compared with registered invasive pneumococcal disease (IPD) data. This study is a part of the ProbiComp study, which was a double-blind, randomized controlled trial, including 290 children allocated to probiotics or placebo for 6 months and recruited during two autumn seasons (2014/2015). Pneumococci were identified by optochin sensitivity, bile solubility, α-hemolysis and/or capsular reaction. Serotyping was performed by latex agglutination kit and Quellung reaction. The carriage rate of S. pneumoniae was 26.0% at baseline and 67.4% at the end of intervention. No significant difference was observed between the placebo group and the probiotics group (p = 0.508). Children aged 8-19 months were carriers of non-pneumococcal vaccine serotypes causing IPD in children aged 0-4 years. However, serotypes causing most IPD cases in Danish elderly were either not found or found with low prevalence suggesting that children are not the main reservoir of those serotypes and other age groups need to be considered as carriers.

Objectives: Bacteria with common microbiological and clinical characteristics are often recognized as a particular group. The acronym HACEK stands for five fastidious genera associated with infective endocarditis (Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, and Kingella). Data on the epidemiology of HACEK are sparse. This article reports a 6-year nationwide study of HACEK bacteraemia in Denmark., Methods: Cases of HACEK bacteraemia occurring during the years 2010-2015 were retrieved from the national Danish microbiology database, covering an average surveillance population of 5.6 million per year., Results: A total of 147 cases of HACEK bacteraemia were identified, corresponding to an annual incidence of 0.44 per 100000 population. The annual incidence for males was 0.56 per 100000 and for females was 0.31 per 100000. The median age was 56 years (range 0-97 years), with variation among the genera. One hundred and forty-three isolates were identified to the species level and six to the genus level: Haemophilus spp, n=55; Aggregatibacter spp, n=37; Cardiobacterium spp, n=9; Eikenella corrodens n=21; and Kingella spp, n=27., Conclusions: This is the first study on the incidence of HACEK bacteraemia in a large surveillance population and may inspire further studies on the HACEK group. Haemophilus spp other than Haemophilus influenzae accounted for most cases of HACEK bacteraemia in Denmark, with Aggregatibacter spp in second place., (Copyright © 2018 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: Infant botulism is a rare, probably underdiagnosed, life-threatening disease caused by the toxin-producing bacterium Clostridium botulinum., Methods: We investigated reported cases of infant botulism in Denmark from 1995 to 2015, and compared the incidence with that of other western countries., Results: We found nine cases of infant botulism in Denmark from 1995 to 2015. The incidence of infant botulism in Denmark was similar to that seen in other western countries, but likely underestimated. The source of infection was only confirmed in a single case. Four cases received botulism immune globulin, intravenous (BIG-IV), which was administered within 7-10 days from admission., Conclusions: Infant botulism is probably underdiagnosed. Increased awareness is crucial to be able to recognise the condition. The time delay from hospital admission to administration of BIG-IV is challenging. Studies have shown that BIG-IV reduces both mean duration of intensive care and mean length of hospital stay; however, this was not confirmed in our work due to the limited number of patients., Funding: none., Trial Registration: not relevant., (Articles published in the DMJ are “open access”. This means that the articles are distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits any non-commercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.)

Haemophilus influenzae is an important human pathogen usually susceptible to quinolones. Here we report the emergence of high-level ciprofloxacin-monoresistant H. influenzae in the Region of Southern Denmark. Four isolates were collected for phenotypic and molecular characterisation using whole-genome sequencing (WGS). During an 18-month period, the occurrence of high-level ciprofloxacin-monoresistant H. influenzae in patients aged 1-77 years from sputum, ear and eye samples was detected. An epidemiological link between the patients could not be identified. The isolates were non-encapsulated, biotype III and were demonstrated by WGS to be clonal belonging to a single clade with an unknown multilocus sequence type (double-locus variant of ST196). The antibiogram demonstrated that they were all monoresistant to ciprofloxacin with a minimum inhibitory concentration (MIC) >32mg/L. In silico resistome analysis revealed identical, both previously characterised and novel, putative resistance-related mutations in gyrA (S84L and D88N), parC (K20R, S84I, D356A or T356A, and M481I) and parE (E151K, I159A, D420N and S599A) in all isolates. The isolates were otherwise negative for any resistance genes. This is the first description of the clonal emergence of high-level monoresistant H. influenzae due to amino acid substitutions in gyrA, parC and parE., (Copyright © 2016 International Society for Chemotherapy of Infection and Cancer. Published by Elsevier Ltd. All rights reserved.)

From January 1st 2011 through June 30th 2011, 116 nonreplicate, noncystic fibrosis-related Pseudomonas aeruginosa isolates with reduced carbapenem susceptibility were collected from 12 out of 13 Danish departments of clinical microbiology. The presence of acquired β-lactamases was assessed with combination tablet-diffusion methodology and polymerase chain reaction. In addition, antimicrobial susceptibility testing, an efflux pump inhibitor assay, and pulsed-field gel electrophoresis (PFGE) were performed. Isolates producing acquired β-lactamases were further investigated by serotyping and multi locus sequence typing. Eight isolates produced the metallo-β-lactamase (MBL) VIM-2, and one isolate produced OXA-10 and VEB-1-like extended-spectrum beta-lactamase (ESBL). Phenotypic indications of derepressed AmpC and efflux pump were seen in 56 and 43 isolates, respectively. Overall, the results indicate that mutational factors related to permeability--often combined with derepressed, chromosomal AmpC--is the main factor behind carbapenem nonsusceptibility in Danish P. aeruginosa isolates. The ESBL producer and all the VIM producers belonged to international clones. PFGE revealed that most of the isolates were unrelated, but clonal spread was seen; the 116 isolates distributed in 97 PFGE types, with the largest cluster consisting of 4 isolates (including three isolates from the same hospital with 100% similarity). Thirty-two isolates were pair-wise related, while the remaining isolates were clonally unrelated, as were all nine ESBL/MBL producers.

Peritonsillar abscess (PTA) is a frequent complication to acute tonsillitis, in particular in adolescents and young adults. Smoking is most commonly initiated during adolescence and young adulthood. The study examines whether smoking increases the risk of PTA and whether smoking is associated with the bacterial findings in PTA. All patients with PTA admitted to the Ear-Nose-Throat Department at Aarhus University Hospital from January 2001 through December 2006 were included in the study. Age- and gender-stratified data on smoking habits in the Danish population and demographic data for Aarhus County for the same 6 years were obtained. Smoking status was available for 679 (80 %) of 847 patients with PTA. 247 (36 %) patients admitted to daily tobacco smoking. Age-stratified odds ratios of smokers compared to non-smokers, for developing PTA, were in the range of 1.9-4.7. Fusobacterium necrophorum and beta-hemolytic streptococci were equally distributed between smokers and non-smokers. Twenty nine percent of the higher incidence of PTA among males compared to females could be explained by a higher prevalence of smoking in males. After correcting for differences in smoking prevalence by gender, the risk of PTA was calculated to be 9.5 % higher among males than females. Smoking was associated with significantly increased risk of PTA in both males and females of all ages. No differences in the microbiological flora of smokers and non-smokers with PTA were found.

Background: The global spread of multi-resistant Enterobacteriaceae is a new challenge in health care. Travelling in high endemic areas has been associated with colonisation. This study was performed among patients hospitalised for any reason, with recent travel abroad to identify the rate for colonisation with multi-resistant bacteria., Methods: In a 3-month period (2011) all patients admitted to a the Department of Infectious Diseases, Aarhus University Hospital, Denmark with a travel history within the last three months were screened for multi-drug resistant bacteria by a rectal swab., Results: A total of 88 adult patients were included. None were carriers of carbapenemase-producing bacilli. 12.5% were colonised with extended spectrum beta-lactamase producing Escherichia coli (ESBL-EC). Diarrhoea during travel was significantly associated with colonisation. More than 80% of the ESBL-EC colonised patients had been abroad longer than two weeks (P < 0.05). Less than 40% of patients with ESBL-EC had self-limiting diarrhoea at the time of admission., Conclusions: A significant proportion of patients with a recent travel history was colonised with ESBL-EC at hospitalisation (12.5%). Less than half of the travellers with ESBL-EC had gastrointestinal symptoms. Diarrhoea during travel and travelling time > two weeks were associated with colonisation with ESBL-EC., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

With the emergence of reduced susceptibility of Clostridium difficile to metronidazole and vancomycin the value of antimicrobial susceptibility testing has increased. The aim of our study was to evaluate disk diffusion for susceptibility testing of C. difficile by comparing disk diffusion results with MICs from gradient tests and to propose zone diameter breakpoint correlates for the EUCAST epidemiological cut-off values (ECOFFs) recently published. We tested 211 clinical isolates of C. difficile, from patients with diarrhoea hospitalized at Aarhus and Odense University Hospitals, Denmark. Furthermore, ten clinical isolates of C. difficile from the Anaerobe Reference Laboratory, University Hospital of Wales, with known reduced susceptibility to either metronidazole or vancomycin, were included. Isolates were tested with Etest gradient strips and disk diffusion towards metronidazole, vancomycin and moxifloxacin on Brucella Blood Agar supplemented with hemin and vitamin K. We found an excellent agreement between inhibition zone diameter and MICs. For each MIC value, the inhibition zones varied from 0 to 8 mm, with 93% of values within 6 mm for metronidazole, 95% of values within 4 mm for vancomycin, and 98% of values within 4 mm for moxifloxacin. With proposed zone diameter breakpoints for metronidazole, vancomycin and moxifloxacin of WT ≥ 23 mm, WT ≥ 19 and WT ≥ 20 mm, respectively, we found no very major errors and only major errors below 2%. In conclusion, we suggest that disk diffusion is an option for antimicrobial susceptibility testing of C. difficile., (© 2012 The Authors. Clinical Microbiology and Infection © 2012 European Society of Clinical Microbiology and Infectious Diseases.)

Background: The degree to which the results of valve culture depend on different laboratory procedures as well as other factors is unknown. The aim of this study was to compare the results of heart valve culture at 2 different endocarditis centres in order to clarify this., Methods: The study included 223 patients with definitive endocarditis undergoing heart valve surgery at 2 Danish endocarditis centres (96 at the East centre and 127 at the West centre). The following data related to the samples were registered: transportation, time to inoculation, culture media used and duration of incubation, species distribution, and preoperative duration of appropriate antimicrobial treatment (DAAT). 16S polymerase chain reaction (PCR) of valve tissue was used to estimate the frequency of non-cultivable bacteria., Results: Valve culture was positive in 12.5% of cases at the East centre and 36.2% at the West centre (p < 0.001). Valve cultures were positive in 10%, 45%, and 58% of cases of streptococcal, staphylococcal, and enterococcal infections, respectively. The median DAAT was 3 days for valve culture-positive cases and 11 days for valve culture-negative cases (p < 0.001). By logistic regression analysis, DAAT, species distribution, and laboratory protocol were identified as independent risk determinants for positive valve culture. The adjusted odds ratio for positive culture by the West centre protocol was 3.0 (confidence interval 1.3-6.9; East = 1, p < 0.01). The valve culture contamination rate was 4% at the East centre and 31% at the West centre (p < 0.01)., Conclusions: Our study showed that the duration of preoperative antibiotic treatment and species distribution must be taken into account when comparing valve culture results. Differences in laboratory protocol explained the 3-fold higher sensitivity of heart valve culture observed in the West centre compared to the East centre.

A three-month laboratory-based prospective survey was conducted at four major university hospitals covering one-third of the Danish population in order to determine the prevalence, significance, and susceptibility pattern of aspergilli in airway samples. Samples received in January-March 2007 for routine microbiologic investigation were examined for Aspergillus following routine procedures and with extended incubation (5 days). Identification was done by morphologic criteria and susceptibility testing using EUCAST method for azoles and amphotericin B E-test. Invasive aspergillosis (IA) was evaluated using modified EORTC/MSG criteria. A total of 11,368 airway samples were received. Growth of Aspergillus spp. was found in 129 and 151 patients using routine and extended incubation, respectively. Three patients had proven IA (2%), 11 probable (7%), four had allergic bronchopulmonary aspergillosis (ABPA) (3%), but the majority was colonised (88%). Underlying conditions were cystic fibrosis in 82 patients (55%), chronic obstructive pulmonary disease in 19 (13%) and haematological disorder in 11 (7%). Twenty-six patients (18%) were at intensive care unit and 69 (47%) received steroid treatment. Azole MICs were elevated for five isolates as follows (itraconazole, posaconazole, voriconazole MICs [mg/L]): two A. fumigatus isolates (>4; >4; 2 and >4; 0.125; 1), one A. lentulus isolate (2; 2; 0.5) and two A. terreus isolates (2; 2; 2 and 2; 0.125; 1). For four isolates the amphotericin B MIC was >1 μg/ml (3/112 A. fumigatus, 1/2 A. terreus). In conclusion, Aspergillus appears to be an important pathogen in Denmark. Elevated itraconazole MICs were detected in 4% of the isolates including a multi-azole resistant isolate.

Different molecular methods for the discrimination of Candida glabrata, C. bracarensis and C. nivariensis were evaluated and the prevalence of these species among Danish blood isolates investigated. Control strains were used to determine fragment length polymorphism in the ITS1, ITS2, ITS1-5.8S-ITS2 regions and in the D1/D2 domain of 26S rDNA using primers designed for this study. A total of 133 blood isolates previously identified as C. glabrata were examined by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) and the peptide nucleic acid-fluorescent in situ hybridization (PNA-FISH) method. The size of ITS1 allowed differentiation between C. glabrata (483), C. nivariensis (361) and C. bracarensis (385), whereas the ITS2 region was of similar size in C. nivariensis (417) and C. glabrata (418). Sequence analysis of the ITS region suggested that many restriction enzymes were suitable for RFLP differentiation of the species. Enzymatic digestion of the D1/D2 domain with TatI produced unique band sizes for each of the three species. PCR-RFLP and PNA-FISH were in agreement for all of the isolates tested. None of the 133 Danish blood isolates were C. nivariensis or C. bracarensis. Fragment size polymorphism of ITS1 and RFLP of the D1/D2 domain or the ITS region are useful methods for the differentiation of the species within the C. glabrata group. C. bracarensis and C. nivariensis are rare among Danish C. glabrata blood isolates.

A 6-year nationwide study of fungemia in Denmark was performed using data from an active fungemia surveillance program and from laboratory information systems in nonparticipating regions. A total of 2,820 episodes of fungemia were recorded. The incidence increased from 2004 to 2007 (7.7 to 9.6/100,000) and decreased slightly from 2008 to 2009 (8.7 to 8.6/100,000). The highest incidences were seen at the extremes of age (i.e., 11.3 and 37.1/100,000 for those <1 and 70 to 79 years old, respectively). The rate was higher for males than for females (10.1 versus 7.6/100,000, P = 0.003), with the largest difference observed for patients >50 years of age. The species distribution varied significantly by both age and gender. Candida species accounted for 98% of the pathogens, and C. albicans was predominant, although the proportion decreased (64.4% to 53.2%, P < 0.0001). C. glabrata ranked second, and the proportion increased (16.5% to 25.9%, P = 0.003). C. glabrata was more common in adults and females than in children and males, whereas C. tropicalis was more common in males (P = 0.020). C. krusei was a rare isolate (4.1%) except at one university hospital. Acquired resistance to amphotericin and echinocandins was rare. However, resistance to fluconazole (MIC of >4 μg/ml) occurred in C. albicans (7/1,183 [0.6%]), C. dubliniensis (2/65 [3.1%]), C. parapsilosis (5/83 [6.0%]), and C. tropicalis (7/104 [6.7%]). Overall, 70.8% of fungemia isolates were fully fluconazole susceptible, but the proportion decreased (79.7% to 68.9%, P = 0.02). The study confirmed an incidence rate of fungemia in Denmark three times higher than those in other Nordic countries and identified marked differences related to age and gender. Decreased susceptibility to fluconazole was frequent and increasing.

Background: Group A streptococci are commonly regarded as the most prevalent cause of acute bacterial tonsillitis and peritonsillar abscess (PTA). However, the majority of PTA aspirates also contain strains of anaerobes, and accumulating evidence indicates that Fusobacterium necrophorum (FN) could be involved in acute tonsillitis. The purpose of the present study was to describe the epidemiology and bacteriology of PTA in Denmark, with particular emphasis on correlations between microbiological, clinical, and laboratory data., Methods: A retrospective study on all patients with PTA admitted to the ear, nose, and throat department at Aarhus University Hospitals from January 2001 through December 2006 was conducted., Results: In total, 847 patients were included in the study. The mean annual incidence of PTA was 41 cases/100,000 population. FN was the most frequently detected bacteria (in 23% of cultures), followed by group A streptococci (in 17%) and groups C and G streptococci (counted together, in 5%). Of the 191 FN isolates detected, 155 (81%) grew as pure culture. Patients infected with FN were significantly younger than patients infected with other strains of bacteria (P < .001). Patients with FN exhibited significantly higher neutrophil counts (P < .001) and C-reactive protein values (P = .01) than did patients infected with other bacteria., Conclusions: To our knowledge, this study is the first report of FN being the most prevalent pathogen in PTA patients. The significantly higher neutrophil counts and C-reactive protein values strongly indicate the pathogenic importance of FN in PTA. The widespread reliance on rapid streptococcal antigen test in general practice to appoint patients for antibiotics and the highest PTA incidence ever reported raise concern that highly virulent bacteria may be left initially untreated.

Background and Aim of the Study: The study aim was to monitor infective endocarditis (IE) before and after the condition was brought into focus in hospitals in the Aarhus region of Denmark., Methods: A total of 172 patients with IE, all of whom had been referred to the regional tertiary center during 2000-2001 or during 2005-2006, was included prospectively into the study., Results: Between 2000-1 (n = 51) and 2005-6 (n = 121), a very large (137%) increase occurred in the number of IE patients referred (p < 0.01). Yet, over this period, the delay from onset of symptoms to admission remained at one month, with a further prolongation of one week (p < 0.05) in 40% of patients who had received pre-hospital antibiotic treatment. A previous healthcare procedure was recorded in 37% of cases, with an ascending trend from 2000-1 to 2005-6. The increase in six-month mortality was high, from 16% to 26%, but was not statistically significant. Independent predictors were prosthetic valve IE (p = 0.02), advanced age (p = 0.03) and co-morbidity (p = 0.05); all three of these features increased over the five-year study interval., Conclusion: Although increased regional hospital attention to IE seemed to facilitate admission to the authors' center, this did not improve survival, apparently because of an unchanged admission delay and increasing age, comorbidity, and prosthetic valve IE. Delayed admission and health care-induced IE were susceptible to modification. Future measures should, therefore, be particularly focused on high-risk patients, on educating the general practitioners, and on improving access to primary healthcare facilities for blood culture and echocardiography.

A semi-national laboratory-based surveillance programme for fungaemia was initiated in 2003 that now covers c. 3.5 million inhabitants (64%) of the Danish population. In total, 1089 episodes of fungaemia were recorded during 2004-2006, corresponding to an annual incidence of 10.4/100 000 inhabitants. The annual number of episodes increased by 17% during the study period. Candida spp. accounted for 98% of the fungal pathogens. Although Candida albicans remained predominant, the proportion of C. albicans decreased from 66.1% in 2004 to 53.8% in 2006 (p <0.01), and varied considerably among participating departments, e.g., from 51.1% at a university hospital in Copenhagen to 67.6% in North Jutland County. Candida glabrata ranked second, and increased in proportion from 16.7% to 22.7% (p 0.04). Candida krusei was isolated rarely (4.1%), but the proportion doubled during the study period from 3.2% to 6.4% (p 0.06). MIC distributions of amphotericin B and caspofungin were in close agreement with the patterns predicted by species identification; however, decreased susceptibility to voriconazole, defined as an MIC of >1 mg/L, was detected in one (2.5%) C. glabrata isolate in 2004 and in 12 (14.0%) isolates in 2006 (p 0.03). Overall, the proportion of isolates with decreased susceptibility to fluconazole exceeded 30% in 2006. The incidence of fungaemia in Denmark was three-fold higher than that reported from other Nordic countries and is increasing. Decreased susceptibility to fluconazole is frequent, and a new trend towards C. glabrata isolates with elevated voriconazole MICs was observed.

In November 2000, we became aware of isolates of Staphylococcus aureus with borderline resistance to oxacillin (BORSA) from patients in the Department of Dermatology, Aarhus University Hospital. The objective was to describe the isolates phenotypically and genotypically and to assess possible transmission routes in order to intervene and prevent further spread. Clonality of the isolates was confirmed by pulsed field gel electrophoresis. Several breaches in infection control procedures were revealed suggesting both direct and indirect transmission between patients. Defective skin barriers, high carrier rates of S. aureus in dermatological patients and high consumption rates of dicloxacillin in the department might facilitate transmission. Following improvement of the general infection control measures, and after reassessment of the antibiotic policy in the department, the outbreak has disappeared.

The aim of this study was to present the first set of comprehensive data on fungemia in Denmark including the distribution of species and range of susceptibility to major antifungal compounds based on a seminational surveillance study initiated in 2003. The catchment area of the participating hospitals had a population of 2.8 million, or 53% of the Danish population. A total of 303 episodes of fungemia were registered (annual rate, 11 of 100,000 people or 0.49 of 1,000 hospital discharges). Candida species accounted for 97.4% of the fungal pathogens. C. albicans was the predominant species (63%), but the proportion varied from 57% to 72% among participating departments of clinical microbiology. C. glabrata was the second most frequent species (20%; range, 8% to 32%). C. krusei was a rare isolate (3%) and occurred only at two of the participating hospitals. Retrospective data retrieved from the Danish laboratory systems documented a continuous increase of candidemia cases since the early 1990s. For the 272 susceptibility-tested isolates, MICs of amphotericin B and caspofungin were within the limits expected for the species or genus. However, decreased azole susceptibility, defined as a fluconazole MIC of >8 microg/ml and/or itraconazole MIC of >0.125 microg/ml, was detected for 11 Candida isolates that were neither C. glabrata nor C. krusei. Including intrinsically resistant fungi, we detected decreased susceptibility to fluconazole and/or itraconazole in 87 (32%) current Danish bloodstream fungal isolates. We showed a continuous increase of fungemia in Denmark and an annual rate in 2003 to 2004 higher than in most other countries. The proportion of bloodstream fungal isolates with reduced susceptibility to fluconazole and/or itraconazole was also notably high.

This study was undertaken to describe the epidemiology, clinical manifestations and prognosis of childhood tuberculosis in Copenhagen, with special attention to differences between Danish children and children of foreign origin. Medical records for all children with tuberculosis cared for in the hospitals of the Copenhagen area 1984-1993 were reviewed. Sixty-six patients were identified. Sixteen of 20 Danish patients (80%) and 67% of foreign children had respiratory tuberculosis. Tuberculosis located in cervical lymph nodes was found only in children of foreign origin. Five patients had meningitis. The high incidence among foreign children reflects the incidence in their home countries, but poorer living conditions among ethnic minorities in Denmark may facilitate transmission of tuberculosis. Severe manifestations of tuberculosis still occur, even in a low incidence country.

This study was undertaken to describe the epidemiology, clinical manifestations and prognosis of childhood tuberculosis in Copenhagen, with special attention to differences between Danish children and children of foreign origin. From 1984-93, 66 children, aged 0-14 years, in the Copenhagen area were notified for tuberculosis. More than two-thirds of the children of foreign origin, including 5 patients from Greenland, who were transferred to Denmark for treatment. A close adult contact with contagious tuberculosis was identified in only a few patients born to foreign parents, but more than one-third had travelled to their homeland within 1 y prior to diagnosis. 48 patients (73%) were reported to have only respiratory tuberculosis. Tuberculosis located in cervical lymph glands was the most frequent nonrespiratory manifestation, but was found only in children of foreign origin. Five patients had meningitis. The high incidence among foreign children reflects the incidence in their home countries, but poorer and more crowded living conditions among ethnic minorities in Denmark may also facilitate transmission of tuberculosis. Severe manifestations of tuberculosis still occur, even in a low incidence country.

The aim of the present study was to characterize all strains of the Mycobacterium avium complex isolated in Denmark in 1993. A total of 141 M. avium complex strains (86 from man, 38 from animals, and 17 from peat) were analysed by serotyping, ELISA specific for a 40 kDa protein, and IS901-specific PCR. Serotype analysis showed that the most frequent serotypes among human strains were serotype 4 (27%) and serotype 6 (19%), which differs from an earlier survey where serotype 1 was most prevalent. The most frequent serotypes in animals were serotype 2 (53%) and serotype 6 (13%), whereas the most prevalent serotypes among strains isolated from peat were serotype 4 (29%) and serotype 9 (18%). There was a concurrent appearance of IS901 and p40 in all strains. Only M. avium complex strains isolated from animals, and belonging to serotype 1 or serotype 2, contained the IS901/p40 markers. The different distribution of serotypes of M. avium complex strains in animals and man, and the presence of IS901/p40 exclusively in animal strains, suggests that transmission of M. avium from animals to man is not of significance in Denmark.