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This study describes the development of structure indicators for hospital antimicrobial stewardship programmes and pilot validation across European hospitals. A multi-disciplinary panel from four European countries developed structure indicators in three steps: identification and listing of indicators, remote ranking of indicators using multi-criteria scoring, selection of indicators in a face-to-face consensus meeting. Additionally, the top-ten indicators were identified as a minimal set of key indicators. A survey was sent to the directors of antimicrobial stewardship programmes in European hospitals. The yes/no answers for the indicators were transformed into numbers in order to calculate the total scores. A list of 58 indicators was selected and categorised into the following topics: antimicrobial stewardship services (12 items), tools (16 items), human resources and mandate (6 items), health care personnel development (4 items), basic diagnostic capabilities (6 items), microbiological rapid tests (2 items), evaluation of microbiological drug resistance data (3 items), antibiotic consumption control (5 items) and drug use monitoring (4 items). The indicator scores, reported by 11 pilot hospitals from five European countries, ranged from 32 to 50 (maximum score = 58) and from 5 to 10 points (maximum score = 10) for, respectively, the complete and the top-ten list. An international panel selected 58 potential structure indicators, among which was a minimal set of ten key structure indicators, that could be useful for assessment of the comprehensiveness and resource-intensity of antimicrobial stewardship programmes. There was significant heterogeneity among participating centres with regard to their score for structural components of effective antimicrobial stewardship. [ABSTRACT FROM AUTHOR]

Rapid and reliable detection of methicillin-resistant Staphylococcus aureus (MRSA) carriers is crucial for control of MRSA nosocomial transmission. We aimed to evaluate the performance of the GeneXpert real-time PCR system using the Xpert MRSA assay on a collection of 40 representative Belgian MRSA strains and for MRSA screening of geriatric inpatients. Double nasal swabs were used: the first swab for the Xpert MRSA assay and the second for culture onto chromogenic selective medium and enrichment broth. All but 1 of the 40 collection strains were recognized as MRSA by the Xpert MRSA assay. Nares swabs were prospectively collected from 246 inpatients including 25 nasal MRSA carriers. Compared with enriched cultures, the sensitivity, the specificity, and the positive and negative predictive values of the Xpert MRSA assay were 69.2%, 97.7%, 78.3%, and 96.3% respectively. The 7 evaluable false-negative results according to the assay were due to its possible lack of sensitivity ( n = 3) and to the occurrence of a Belgian MRSA clone carrying a particular staphylococcal chromosomal cassette mec (SCC mec) type IV variant ( n = 4) not targeted by the current Xpert MRSA assay. Because of the evolution of SCC mec in MRSA, new primers should be designed and further studies are warranted to ensure continuous monitoring of this assay. [ABSTRACT FROM AUTHOR]

There is an urgent public health need for early and reliable detection of methicillin-resistant Staphylococcus aureus (MRSA) infection and carriage to direct antibiotic therapy, to inform patient isolation and decontamination procedures, and to more effectively control cross-infection. Limited advances have been made in culture-based tests, while considerable promise is offered by a new generation of molecular assays based on real-time PCR. Several commercially available PCR tests can rapidly detect MRSA from nasal swabs with high sensitivity and specificity (both 90-100%), although technical issues remain to be resolved and comparative data are lacking. Crucially, evidence must be provided for the clinical efficacy, effectiveness and cost-benefit of implementing these technologies. Furthermore, adaptations in healthcare systems and professional behaviour will be required if full advantage is to be taken of any truly rapid, point-of-care tests that become available. [ABSTRACT FROM AUTHOR]

Reported here is a case ofBacillus cereuspneumonia that occurred in a patient with acute lymphoblastic leukemia. The presentation was severe, essentially marked by respiratory distress and pleuritic chest pain. Classic empirical treatment initiated for febrile neutropenia did not cover this rare pathogen and appropriate therapy was therefore delayed.B. cereusis most often a culture contaminant, but it can also be responsible for self-limited gastrointestinal intoxication and, more rarely, severe systemic diseases. Virulence in the case of systemic disease is attributed to tissue necrosis mediated by toxin release.B. cereuspneumonia, as described in the English-language literature, mainly affects immunocompromised patients and most often has a fatal outcome. Thus, the identification ofB. cereusin clinical specimens of severely ill immunocompromised patients should lead physicians to question its clinical significance. [ABSTRACT FROM AUTHOR]

This pan-European study included unrelated strains of Legionella pneumophila obtained from 1,335 cases of Legionnaires' disease. The isolates were serotyped into the serogroups 1 to 15 by monoclonal antibodies (MAb) and/or rabbit antisera. Additionally, MAb subgrouping was undertaken for isolates belonging to serogroups 1, 4, and 5. Monoclonal types of serogroup 1 were subdivided as having, or not having, the virulence-associated epitope recognized by the MAb 3/1 (Dresden Panel). This epitope is not present on strains belonging to any other serogroups. Taking all Legionella incidents together, MAb 3/1-positive cases were most frequent (66.8%); 11.7% of the isolates belonged to MAb 3/1-negative serogroup 1 subgroups and 21.5% to other serogroups, with serogroups 3 and 6 predominating. Among all serotypes discriminated in this study, monoclonal subtype Philadelphia was the most frequent. If categories of infection were considered, the proportion of MAb 3/1-negative strains differed significantly (P<0.0005) between community-acquired cases (139/510; 27.3%) and travel-associated (42/295; 14.2%) or hospital-acquired infections (176/329; 53.5%). Moreover, taking distribution in different European areas into account, the proportion of MAb 3/1-negative strains was significantly higher in the Scandinavian region than in the Mediterranean countries or the UK for both community-acquired (48.7% vs. 18.6% or 12.0%; P<0.0005) and nosocomial cases (87.7% vs. 32.6% or 52.6%; P≤0.0007). [ABSTRACT FROM AUTHOR]

Pulsed-field gel electrophoresis and polymerase chain reaction genome fingerprinting based on repetitive chromosomal sequences (rep-PCR) were used for typing 14 strains of Ochrobactrum anthropi. Six strains isolated during an outbreak of bacteraemia in patients who had received a contaminated rabbit anti-thymocyte globulin gave identical patterns by both techniques. Different patterns were found in sporadic and reference strains, except for one clinical isolate received from another hospital that showed the same pattern as the epidemic clone. This patient had also received rabbit anti-thymocyte globulin from the same source at the time of the outbreak. This study illustrates the advantages of genetic typing methods in terms of high typeability and discriminating power, even for rare pathogens. Furthermore, it highlights the need for interhospital communication for effective identification of common sources of outbreaks related to intrinsic drug contamination. [ABSTRACT FROM AUTHOR]

A questionnaire survey of Belgian acute care hospitals was conducted to determine the methods used for detection of methicillin-resistant Staphylococcus aureus (MRSA), to estimate the prevalence of this organism during the period 1989-1991 and to describe the infection control measures used locally for limiting its spread. Questionnaires were returned by 144 acute care hospitals, with a coverage of 41 to 72 % of hospitals by province. Methods used for detection of MRSA included disk diffusion (91 %), microdilution panels (8 %) and oxacillin agar screen (9 %). Only 34 % of laboratories performed disk diffusion testing under optimal conditions for detection of heterogeneous resistance. Among 36 hospitals reporting complete susceptibility data of Staphylococcus aureus isolates tested during the study period (n=24,153), a mean MRSA prevalence of 14 % was found (range: 0-70 %). The median prevalence increased from 9.5 % in 1989 to 13.7 % in 1991 and showed a significant linear increase during this period in 30 % of these hospitals (p<0.01). Precautions used for controlling spread of MRSA included hand decontamination using either soap and water or antimicrobial preparations (68 % of hospitals), room decontamination (62 %), patient isolation (55 %) and various barrier precautions (24-49 %). Carrier screening was performed in 37 % of hospitals, but antibiotic decolonization was attempted in only 24 %. This survey identified areas for improvement in MRSA detection methods and underscored the need for multicentric surveillance of MRSA prevalence and a reappraisal of MRSA control strategies in Belgian hospitals. [ABSTRACT FROM AUTHOR]

To determine the role of bacterial and host factors in the pathogenesis of shigellemia, blood and fecal Shigella isolates were compared for serum resistance and siderophore production, and shigellemic patients were examined for decreased serum bactericidal activity or increased serum transferrin saturation compared to control patients with non-bacteremic shigellosis. The majority of both blood (36/38) and fecal (36/48) Shigella isolates were sensitive to normal serum (> 2 log kill/60 min). Shigella dysenteriae type 1 strains were the most sensitive, and Shigella sonnei strains were the most resistant. Siderophore production was species- and serotype-dependent. Shigella dysenteriae type 1 produced only enterochelin; most Shigella flexneri expressed only aerobactin, and Shigella sonnei secreted both types of siderophores. No difference in siderophores was noted between blood and fecal strains within a given serotype. In contrast, shigellemic patients exhibited a 43-fold decrease in serum bactericidal activity and a two-fold increase in transferrin saturation compared to well-nourished control patients. These results indicate that the pathogenesis of Shigella septicemia is not related to serum resistance or siderophore production but may involve serum abnormalities associated with malnutrition. [ABSTRACT FROM AUTHOR]

Context: Surveillance of antibiotic resistance is especially important in intensive care units (ICUs) because the infection rates are much higher there than in other hospital wards and most epidemics with multiresistant bacteria originate in ICUs.Objective: To evaluate the incidence of decreased antibiotic susceptibility among aerobic gram-negative bacilli isolated from patients in ICUs.Design: Consecutive specimens collected on clinical indications from ICU patients were cultured and tested. Minimum inhibitory concentrations for amikacin, ceftazidime, ceftriaxone, ciprofloxacin, gentamicin, imipenem, piperacillin, and piperacillin-tazobactam were determined using E test.Setting: Eighteen hospitals in Belgium, 40 in France, 20 in Portugal, 30 in Spain, and 10 in Sweden.Subjects: A total of 9166 gram-negative strains were initially isolated from 7308 patients between June 1994 and June 1995.Main Outcome Measures: The incidence of decreased susceptibility, defined as the sum of resistant and intermediate categories with use of the minimum inhibitory concentration break points recommended by the National Committee for Clinical Laboratory Standards.Results: The most frequently isolated organisms were Enterobacteriaceae (59%) followed by Pseudomonas aeruginosa (24%). The main sources were respiratory tract (42%), urine (26%), blood (14%), abdomen (11%), and skin and soft tissue (7%). Decreased antibiotic susceptibility across all species and drugs was highest in Portuguese ICUs followed by French, Spanish, Belgian, and Swedish ICUs. The highest incidence of resistance was seen in all countries among P aeruginosa (up to 37% resistant to ciprofloxacin in Portuguese ICUs and 46% resistant to gentamicin in French ICUs), Enterobacter species, Acinetobacter species, and Stenotrophomonas maltophilia, and in Portugal and France among Klebsiella species.Conclusion: The high incidence of reduced antibiotic susceptibility among gram-negative bacteria in these ICUs suggests that more effective strategies are needed to control the selection and spread of resistant organisms. [ABSTRACT FROM AUTHOR]

Epidemiologic and clinical features of infection with Campylobacter jejuni in Bangladesh were examined in (1) diarrheal patients infected with C jejuni, (2) healthy control subjects, and (3) village children who were cultured monthly and at each diarrheal episode during a 10-month period. C jejuni was isolated from 437 (14%) of 3,038 outpatients with diarrhea. These patients had no distinct clinical presentation and were more likely to have a mixed infection than were patients infected with other pathogens (59% vs 42%, P < 0.01). Age-specific infection rates were greatest in infants and did not differ significantly from those in control subjects. C jejuni was isolated less frequently from village children with diarrhea than from those cultured routinely (5% vs 9%, P <0.05). Forty percent of 47 patients with C jejuni vs 23% of 48 control subjects (P < 0.01) had an elevated convalescent-phase antibody titer as determined by complement fixation test. In Bangladesh, enteric infection with C jejuni is common but often asymptomatic, although pathogenicity is suggested by serologic response in some patients. [ABSTRACT FROM PUBLISHER]