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Background: Data on outpatient macrolide, lincosamide and streptogramin (MLS) use in Europe were collected from 25 countries within the ESAC project, funded by DG SANCO of the European Commission, using the WHO ATC/DDD methodology. Methods: For the period 1997-2003, data on outpatient use of systemic MLS aggregated at the level of the active substance were collected and expressed in DDD (WHO, version 2004) per 1000 inhabitants per day (DID). Macrolide use was analysed in detail, using a classification based on their mean plasma elimination half-life. Results: Total outpatient MLS use in 2003 varied by a factor of 11 between the country with the highest (9.36 DID in Greece) and lowest (0.85 DID in Sweden) use. MLS use showed high seasonal variation. Short-, intermediate- and long-acting macrolides were used most in 6, 18 and 1 countries, respectively (mainly erythromycin, clarithromyin and azithromycin, respectively). Lincosamide use was observed in all countries (mainly clindamycin) and substantial streptogramin use only in France (pristinamycin). From 1997 to 2003, MLS use increased in 14 countries and was most pronounced in Greece (increase of >5 DID). Except for Sweden, a relative increase of intermediate- (mainly clarithromycin) and/or long- acting (mainly azithromycin) macrolide use was observed, at the expense of short-acting macrolide (mainly erythromycin) use. Conclusion: The observed differences between European countries in the levels of MLS use and the extreme seasonal variations in their use suggest that this class of antibiotics is prescribed inappropriately in many countries. The MLS classification developed here facilitates a more comprehensive description of macrolide use in Europe. These data (collected as part of ESAC) could promote investigations that lead to a deeper understanding of the link between macrolide use and resistance.

The creation of a database intended for the comparative analysis of the rates of hospital-acquired infections in the 15 countries of the European Union is among the objectives of the HELICS network (Hospitals in Europe Link for Infection Control through Surveillance).

The object of this article was to validate the predictive value of Charlson's comorbidity index for the prediction of short-term mortality or morbidity in elderly people. The design was a cohort study comparing survival and hospitalization in institutionalized elderly people with different levels of comorbidity at baseline. The setting was 16 Flemish nursing homes for the elderly. The subjects were 2,727 inhabitants of which full data were available for 2,624. The outcome measures were hazard ratios resulting from Cox regression analysis, comparing 6 months survival in patients with moderate and a high level to low level of comorbidity. Odds ratios resulting from multiple logistic regression analysis comparing the occurrence of at least one hospitalization during the follow-up period in surviving patients of the same groups. Mortality adjusted for age group was significantly increased in patients with a moderate (HR = 2.00) and even more in those with a high level (HR = 3.62) of comorbidity. Hospitalization was more frequent in both groups (OR = 1.54 and 2.19, respectively), with statistical significance only being reached for the highest group. Adjustment for age, gender, mobility status, and disorientation did not change the general picture. Charlson's comorbidity index is a predictor of short-term mortality in institutionalized elderly patients and, to a lesser extend, also of hospitalization. These results support its use as a measure for introducing comorbidity as a covariable in longitudinal studies with a geriatric population.

A cross-sectional study of methicillin-resistantStaphylococcus aureuscarriage in 2,857 nursing home residents showed an overall prevalence of 4.9%. The three clones identified by genetic analysis were identical to those in the acute care facilities; only their relative prevalence differed. Clone 2 took epidemic proportions in five of these nursing homes.

Marie-Laurence Lambert and colleagues did a large retrospective study in intensive care units (ICU) from ten European countries. They concluded that ICU-acquired pneumonia and bloodstream infections substantially increased mortality and ICU stay, while the additional eff ect of antibiotic resistance in this group of patients was relatively modest. We believe that this study design is unlikely to fully capture the public health eff ect of antibiotic resistance for two reasons: fi rst, patients with bacterial infection in ICUs often receive early empirical treatment that typically covers the resistance phenotypes that the authors chose as exposures; and second, the median follow-up was limited to 5 days, and this short follow-up might have concealed the long-term eff ects of treatment failure. The authors included a summary estimate for the eff ect of resistance in their discussion, thereby neglecting the pathogenspecifi c eff ect of antibiotic resistance on mortality. We have reported data for more than 2000 patients with Staphylococcus aureus or Escherichia coli bloodstream infections with follow-up beyond hospital discharge, and pathogen-specifi c estimates showed that resistance increased mortality 30-days after infection by 80–150%. In a study with 90-day follow-up, the hazard of death in those with meticillin-resistant S aureus bacteraemia was twice that of meticillin-sensitive S aureus. We conclude that to address the burden of disease attributable to antibiotic resistance, comprehensive enrolment of patients is needed, including those in non-ICU settings, with follow-up beyond hospital discharge and a pathogen-specifi c approach to inform health-care providers and the public about the importance of this health threat.