Prolonged watery diarrhea and malnutrition caused by Aliarcobacter butzleri (formerly Arcobacter butzleri): the first pediatric case in Croatia and a literature review.

Aliarcobacter butzleri (formerly Arcobacter butzleri), is a newly recognized Campylobacter-like emerging foodborne pathogen worldwide, usually causing gastrointestinal symptoms in young children. A 4-year-old boy was admitted to the Department of Pediatrics, University Hospital of Split, Croatia, because of malnutrition, lost appetite and prolonged watery diarrhea. A comprehensive diagnostics, including biochemistry, haematology, allergology, microbiology and radiology, were performed. The only positive microbiology result was unexpected isolation of Aliarcobacter butzleri on selective media for Campylobacter, after 48 hours of incubation on 42°C, among microaerophilic atmosphere. Clinical course was favorable and after symptomatic therapy child was discharged in good clinical condition and normal peristalsis to home care, with the recommendation of taking high-protein preparations to improve nutritional status. In addition, we performed a literature review of clinical cases caused by Aliarcobacter butzleri infection. The first report of Aliarcobacter butzleri isolated from stool sample in a 4-year old boy in Croatia, along with other clinical reports in literature, highlights the importance of standardisation and improvement of microbiological analysis, especially implementation of new methods for the identification of emerging pathogens.

Antimicrobial resistance surveillance of Bacteroides fragilis isolated from blood cultures, Europe, 2022 (ReSuBacfrag).

BACKGROUND: Bacteroides fragilis is the most frequent cause of anaerobic bacteraemia. Although recent data suggest a rise in antimicrobial resistance (AMR) of this and other anaerobic bacteria, surveillance remains limited due to a lack of both data availability and comparability. However, a newly introduced standardised method for antimicrobial susceptibility testing (AST) of anaerobic bacteria has made larger scale surveillance possible for the first time. AIM: To investigate phenotypic AMR of Bacteroides fragilis isolates from bacteraemia across Europe in 2022. METHODS: In a multicentre approach, clinical microbiology laboratories in Europe were invited to contribute results of AST for Bacteroides fragilis blood culture isolates (including only the first isolate per patient and year). AST of a selection of four antibiotics was performed locally by participating laboratories in a prospective or retrospective manner, using the new EUCAST disc diffusion method on fastidious anaerobe agar (FAA-HB). RESULTS: A total of 16 European countries reported antimicrobial susceptibilities in 449 unique isolates of Bacteroides fragilis from blood cultures in 2022. Clindamycin demonstrated the highest resistance rates (20.9%, range 0 - 63.6%), followed by piperacillin-tazobactam (11.1%, 0 - 54.5%), meropenem (13.4%, 0 - 45.5%), and metronidazole (1.8%, 0 - 20.0%), all with wide variation between countries. CONCLUSION: Considering that the mean resistance rates across Europe were higher than expected for three of the four anti-anaerobic antibiotics under surveillance, both local AST of clinically relevant isolates of Bacteroides fragilis and continued surveillance on an international level is warranted.

Phenotypic and Molecular Characterization of a Hospital Outbreak Clonal Lineage of Salmonella enterica Subspecies enterica serovar Mikawasima Containing blaTEM-1B and blaSHV-2 That Emerged on a Neonatal Ward, During the COVID-19 Pandemic.

Nontyphoid salmonella can cause severe infections in newborns and is therefore declared a pathogen of major health significance at this age. The aim of the study was molecular and antimicrobial characterization of ß-lactamase-producing Salmonella Mikawasima outbreak clone on a Neonatal ward, University Hospital of Split (UHS), Croatia during the COVID-19 pandemic. From April 2020, until April 2023, 75 nonrepetitive strains of Salmonella Mikawasima were isolated from stool specimens and tested for antimicrobial resistance. All 75 isolates were resistant to ampicillin and gentamicin, while 98% of isolates were resistant to amoxicillin/clavulanic acid. A high level of resistance was observed to third-generation cephalosporins (36% to ceftriaxone and 47% to ceftazidime). Extended-spectrum ß-lactamase production was phenotypically detected by double-disk synergy test in 40% of isolates. Moderate resistance to quinolones was detected; 7% of isolates were resistant to pefloxacin and ciprofloxacin. All isolates were susceptible to carbapenems, chloramphenicol, and co-trimoxazole. Fourteen representative isolates, from 2020, 2021, 2022, and 2023, were analyzed with PFGE and all of them belong to the same clone. Whole-genome sequencing (WGS) analysis of three outbreak-related strains (SM1 and SM2 from 2020 and SM3 from 2023) confirmed that these strains share the same serotype (Mikawasima), multilocus sequence typing profile (ST2030), resistance genes [blaTEM-1B, aac(6')-Iaa, aac(6')-Im, and aph(2'')-Ib)] and carry incompatibility group C (IncC) plasmid. Furthermore, the gene blaSHV-2 was detected in SM1 and SM2. In summary, WGS analysis of three representative strains clearly demonstrates the persistence of ß-lactamase-producing Salmonella Mikawasima in UHS during the 4-year period.

Molecular characterization of colistin resistance genes in a high-risk ST101/KPC-2 clone of Klebsiella pneumoniae in a University Hospital of Split, Croatia.

Klebsiella pneumoniae carbapenemase-producing K. pneumoniae (KPC-KP) has become a major concern worldwide due to multidrug resistance and the ability to spread locally and globally. Infections caused by KPC-KP are great challenge in the healthcare systems because these are associated with longer hospitalization and high mortality. The emergence of colistin resistance has significantly reduced already limited treatment options. This study describes the molecular background of colistin-resistant KPC-KP isolates in the largest hospital in southern Croatia. Thirty-four non-duplicate colistin-resistant KPC-KP isolates were collected during routine work from April 2019 to January 2020 and from February to May 2021. Antimicrobial susceptibility was determined using disk diffusion, broth microdilution, and the gradient strip method. Carbapenemase was detected with an immunochromatographic test. Identification of blaKPC and mcr genes or mutations in pmrA, pmrB, mgrB, phoP, and phoQ genes were performed by polymerase chain reaction (PCR) and positive products were sequenced. Pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST) were used for epidemiological analysis. All isolates were multidrug-resistant, with colistin minimum inhibitory concentrations (MICs) from 4 to >16 mg/L, and all harbored blaKPC-2 and had a single point mutation in the mgrB gene resulting in a premature stop codon, with the exception of one isolate with four point mutations corresponding to stop codons. All isolates were negative for mcr genes. PFGE analysis identified a single genetic cluster, and MLST revealed that all isolates belonged to sequence type 101 (ST101). These results show emergence of the high-risk ST101/KPC-2 clone of K. pneumoniae in Croatia as well as appearance of colistin resistance due to mutations in the mgrB gene. Molecular analysis of epidemiology and possible resistance mechanisms are important to develop further strategies to combat such threats.

Microbiome profiling and characterization of virulent and vancomycin-resistant Enterococcus faecium from treated and untreated wastewater, beach water and clinical sources.

Vancomycin-resistant Enterococcus faecium (VREfm) is an opportunistic pathogen among the highest global priorities regarding public and environmental health. Following One Health approach, we determined for the first time the antibiotic resistance and virulence genes, and sequence types (STs) affiliation of VREfm recovered simultaneously from marine beach waters, submarine outfall of a wastewater treatment plant and an offshore discharge of untreated sewage, and compared them with the surveillance VREfm from regional university hospital in Croatia to assess the hazard of their transmission and routes of introduction into the natural environment. Importantly, VREfm recovered from wastewater, coastal bathing waters and hospital shared similar virulence, multidrug resistance, and ST profiles, posing a major public health threat. All isolates carried the vanA gene, while one clinical isolate also possessed the vanC2/C3 gene. The hospital strains largely carried the aminoglycoside-resistance genes aac(6')-Ie-aph(2″)-Ia, and aph(2″)-Ib and aph(2″)-Id, which were also predominant in the environmental isolates. The hyl gene was the most prevalent virulence gene. The isolates belonged to 10 STs of the clonal complex CC17, a major epidemic lineage associated with hospital infections and outbreaks, with ST117 and ST889 common to waterborne and hospital isolates, pointing to their sewage-driven dissemination. To gain better insight into the diversity of accompanying taxons in the surveyed water matrices, microbiome taxonomic profiling was carried out using Illumina-based 16S rDNA sequencing and their resistome features predicted using the PICRUSt2 bioinformatics tool. An additional 60 pathogenic bacterial genera were identified, among which Arcobacter, Acinetobacter, Escherichia-Shigella, Bacteroides and Pseudomonas were the most abundant and associated with a plethora of antibiotic resistance genes and modules, providing further evidence of the hazardous effects of wastewater discharges, including the treated ones, on the natural aquatic environment that should be adequately addressed from a sanitary and technological perspective.

A RARE PRESENTATION OF GENITOURINARY TUBERCULOSIS MIMICKING ABDOMINAL TUMOR.

Genital tuberculosis is a rare and unexpected disease in European countries including Croatia. Diagnosis of female genital tract tuberculosis is challenging and is rarely pin-pointed by clinical symptoms because of their low specificity. The authors decided to present a case of genitourinary tuberculosis in a young, immunocompetent fertile woman with high clinical suspicion of abdominal tumor mass. Although considered a desease of the past, rare clinical presentation of genital tuberculosis should be expected and taken into account.

Submarine Outfalls of Treated Wastewater Effluents are Sources of Extensively- and Multidrug-Resistant KPC- and OXA-48-Producing Enterobacteriaceae in Coastal Marine Environment.

The rapid and ongoing spread of carbapenemase-producing Enterobacteriaceae has led to a global health threat. However, a limited number of studies have addressed this problem in the marine environment. We investigated their emergence in the coastal waters of the central Adriatic Sea (Croatia), which are recipients of submarine effluents from two wastewater treatment plants. Fifteen KPC-producing Enterobacteriaceae (nine Escherichia coli, four Klebsiella pneumoniae and two Citrobacter freundii) were recovered, and susceptibility testing to 14 antimicrobials from 10 classes showed that four isolates were extensively drug resistant (XDR) and two were resistant to colistin. After ERIC and BOX-PCR typing, eight isolates were selected for whole genome sequencing. The E. coli isolates belonged to serotype O21:H27 and sequence type (ST) 2795, while K. pneumoniae isolates were assigned to STs 37 and 534. Large-scale genome analysis revealed an arsenal of 137 genes conferring resistance to 19 antimicrobial drug classes, 35 genes associated with virulence, and 20 plasmid replicons. The isolates simultaneously carried 43-90 genes encoding for antibiotic resistance, while four isolates co-harbored carbapenemase genes bla KPC-2 and bla OXA-48. The bla OXA-48 was associated with IncL-type plasmids in E. coli and K. pneumoniae. Importantly, the bla KPC-2 in four E. coli isolates was located on ~40 kb IncP6 broad-host-range plasmids which recently emerged as bla KPC-2 vesicles, providing first report of these bla KPC-2-bearing resistance plasmids circulating in E. coli in Europe. This study also represents the first evidence of XDR and potentially virulent strains of KPC-producing E. coli in coastal waters and the co-occurrence of bla KPC-2 and bla OXA-48 carbapenemase genes in this species. The leakage of these strains through submarine effluents into coastal waters is of concern, indicating a reservoir of this infectious threat in the marine environment.

Endemicity of OXA-23 and OXA-72 in clinical isolates of Acinetobacter baumannii from three neighbouring countries in Southeast Europe.

According to the World Health Organization, bacterium Acinetobacter baumannii is the first on the critical priority list of pathogens in urgent need for new antibiotics. The increasing resistance of A. baumannii to the last-line treatment options, including carbapenems, is a global problem. We report the molecular epidemiology of 12 carbapenem-resistant clinical isolates of A. baumannii collected from hospitalised patients in three neighbouring countries in Southeast Europe: Croatia, Serbia, and Bosnia and Herzegovina, giving an insight into the molecular characterisation and evolutionary history of the acquisition of resistance genes. Besides the blaOXA-23 gene, the endemic presence of OXA-72 oxacillinase of the same origin for more than a decade as the leading mechanism of carbapenem resistance in Southeast Europe was confirmed. To the best of our knowledge, this is the first paper that investigates and analyses the phylogenetic association of the most common mechanisms of resistance to carbapenems in clinical isolates of A. baumannii originating from three neighbouring countries in Southeast Europe.

Molecular Characterization of ß-Lactam Resistance and Antimicrobial Susceptibility to Possible Therapeutic Options of AmpC-Producing Multidrug-Resistant Proteus mirabilis in a University Hospital of Split, Croatia.

This study was performed to elucidate genetic relatedness and molecular resistance mechanisms of AmpC-producing multidrug-resistant Proteus mirabilis isolates in University Hospital of Split (UHS), and define efficient antibiotics in vitro. A total of 100 nonrepeated, consecutive, amoxicillin/clavulanate- and cefoxitin-resistant P. mirabilis isolates were collected, mostly from urine (44%) and skin and soft-tissue samples (30%). They were all positive in cefoxitin Hodge test and negative for extended spectrum beta-lactamase production. Pulsed field gel electrophoresis identified four clusters and two singletons, with 79% of isolates in dominant cluster. Molecular characterization and I-CeuI analysis of representatives revealed blaCMY-16 gene located on chromosome, and insertion element ISEcp1 positioned 110 pb upstream of blaCMY-16 starting codon. They also harbored blaTEM-1, except one with blaTEM-2. They were all resistant to trimethoprim-sulfamethoxazole, all but one to quinolones, and 81% to all aminoglycosides, while 77% were susceptible (S) and 22% intermediate (I) to piperacillin/tazobactam, and 4% were S and 68% I to cefepime. Only 15% were S to ceftolozane/tazobactam. Meropenem, ertapenem, ceftazidime/avibactam, temocillin, and fosfomycin were 100% efficient in vitro. This is the first report of blaCMY-16 gene in P. mirabilis from hospital samples in Croatia. The findings are in accordance with Italian and Greek reports. The clonal nature of outbreak suggests the high potential of clonal spread. Alternative agents should be considered to spare carbapenem usage.

Vancomycin-resistant Enterococcus faecium COLONIZATION and Clostridium difficile infection in a HEMATOLOGIC patient.

Vancomycin-resistant enterococci (VRE), especially Enterococcus faecium, have emerged as significant nosocomial pathogens and patients with impaired host defenses are at a particular risk of VRE infection. The most common occurrence is asymptomatic colonization of the gastrointestinal tract that can persist for a long time and serve as a reservoir for transmission of VRE to other patients. We present a case of a patient who was diagnosed with acute myelogenous leukemia and suffered from bone marrow aplasia following induction therapy. The patient received prolonged broad-spectrum antimicrobial therapy. During hospital stay, the patient developed Clostridium difficile infection (CDI) and was found to be colonized with a strain of Enterococcus faecium resistant to vancomycin during therapy for CDI. This case also highlights the role of risk factors that could contribute to development of resistance, particularly CDI. Early detection of VRE colonization or infection is a crucial component in hospital program designed to prevent transmission of nosocomial infections. Surveillance cultures of such patients should be mandatory.

Mycobacterium shimoidei-cavitary pulmonary disease with favorable outcome.

We report a case of cavitary pulmonary disease caused by Mycobacterium shimoidei in 67-year-old female with history of asthma. Even though susceptibility testing was not available, choice of treatment regimen (streptomycin, rifampicin, ethambutol, and clarithromycin), based on a few cases with favorable outcome reported in the literature, resulted with an excellent clinical, microbiological, and radiological response. This is the first report of pulmonary disease caused by M. shimoidei, but also the first ever isolation of M. shimoidei in Croatia.

Transmission and survival of carbapenem-resistant Acinetobacter baumannii outside hospital setting.

Acinetobacter baumannii origin and its epidemiology is under a great concern worldwide since this microorganism has become a leading nosocomial pathogen of the 21th century among the "ESKAPE" group of microorganisms. The aim of the study was to monitor and explore the epidemiology of this important hospital pathogen in the second largest clinical university hospital in Croatia. The presence of A. baumannii in hospital wastewater, as a route for possible transmission outside of the hospital setting, as well as its survival in environmental conditions including seawater, was investigated. During the examination period, ten both carbapenem and multidrug-resistant isolates of A. baumannii were recovered from hospital wastewater and compared to the clinical isolates originating from the same monitoring period. Multiplex PCR confirmed that four wastewater isolates harboured blaOXA-23-like, while five wastewater isolates harboured blaOXA-40-like genes sharing 100% sequence identity with blaOXA-72 sequence described in the same hospital in 2009, confirming the presence of an endemic cluster. Survival of A. baumannii in natural seawater was examined during 50 days of monitoring and to the best of our knowledge, was performed for the first time.

Campylobacter jejuni strains coresistant to tetracycline and ciprofloxacin in patients with gastroenteritis in Croatia.

BACKGROUND: Antibiotic-resistant Campylobacter jejuni strains are rapidly emerging worldwide. Here, we aimed to determine the antibiotic-resistance patterns and genetic structure of C. jejuni from stool samples of symptomatic patients in Dalmatia, the largest Croatian county. METHODS: In a population-based laboratory surveillance programme for campylobacteriosis in Dalmatia from May 2012 to May 2013, C. jejuni (n = 76) were collected from stool samples of all the patients hospitalized with gastroenteritis and matched positive outpatients (n = 77). Antibiotic susceptibility testing and pulsed-field gel electrophoresis (PFGE) genotyping of isolates were performed. RESULTS: Approximately 60% of the isolates were resistant to ciprofloxacin, whereas 24% of isolates were resistant to tetracycline; of the latter, 89% were also coresistant to ciprofloxacin. Resistance to erythromycin and gentamicin was infrequent (≤ 0.7%). Antibiotic-resistant strains were generally not associated with the need for hospitalization. However, the prevalence of coresistant strains increased sharply after 2010, and these coresistant strains were more prevalent in infections caused by clonal PFGE types, with distinct patterns of temporal occurrence and age distribution in infected patients. CONCLUSION: A high prevalence of coresistant TcR/CipR C. jejuni strains were detected in patients in Croatia. Strains were significantly associated with several clonal-type PFGE genotypes, shared common patterns of temporal occurrence, and showed distinct age distribution in infected patients, suggestive of newly identified strains. Since a high prevalence of coresistant TcR/CipR strains was also observed in other countries, further in-depth studies are essential to evaluate whether this phenomenon is linked to C. jejuni epidemiology in food animals and agricultural ecosystems.

No difference in the intention to engage others in academic transgression among medical students from neighboring countries: a cross-national study on medical students from Bosnia and Herzegovina, Croatia, and Macedonia.

AIM: To asses if the level of intention to engage others in academic transgressions was comparable among medical students from five schools from neighboring Southern-European countries: Croatia, Bosnia and Herzegovina, and Macedonia; and medical students from western EU studying at Split, Croatia. METHODS: Five medical schools were surveyed in 2011, with ≥87% of the targeted population sampled and a response rate of ≥76%. Students' intention to engage a family member, friend, colleague, or a stranger in academic transgression was measured using a previously validated the Intention to Engage Others in Academic Transgression (IEOAT) questionnaire and compared with their intention to ask others for a non-academic, material favor. Data on students' motivation measured by Work Preference Inventory scale, and general data were also collected. Multiple linear regression models of the intention to engage others in a particular behavior were developed. RESULTS: The most important determinants of the intention to engage others in academic transgression were psychological factors, such as intention to ask others for a material favor, or students' motivation (median determinant's ß of 0.18, P≤0.045 for all), whereas social and cultural factors associated with the country of origin were either weak (median ß of 0.07, P≤0.031) or not relevant. A significant proportion of students were aware of the ethical violations in academic transgressions (P≤0.004 for all transgressions), but a large proportion of students also perceived academic cheating as a collective effort and were likely to engage people randomly (P≤0.001 for all, but the most severe transgression). This collective effort was more pronounced for academic than non-academic behavior. CONCLUSION: Culture differences among neighboring Southern-European countries were not an important determinant of the intention to engage others in academic cheating.

Evaluation of PNA FISH® Yeast Traffic Light in identification of Candida species from blood and non-blood culture specimens.

PNA FISH(®) (peptide nucleic acid fluorescent in situ hybridization) Yeast Traffic Light (PNA FISH(®) YTL) assay is a commercially avaliable method for rapid identification of Candida spp. directly from positive blood cultures. This report provides a one-year experience in identification of yeasts from 25 specimens (15 positive blood cultures and 10 other clinically significant specimens) using PNA FISH(®) YTL and comparing it to VITEK 2 System. Overall, assay identification compatibility with VITEK 2 System was found among 21/25 (84%) isolates tested. Only 3/25 (12%) of the isolates were not identified, and one isolate was misidentified by the PNA FISH(®) YTL assay. Our results show that the assay is a reliable method in identification of Candida spp. not only from blood cultures, but even from other clinically significant specimens (urine cultures, catheter tip cultures, peritoneal fluid cultures) when compared to automated method like VITEK 2 System. This novel application of the PNA FISH(®) YTL assay could therefore contribute to cost savings and significant benefit to patients, as rapid information about isolated yeast species is provided.

Geotrichum capitatum respiratory tract infection in a patient with polytrauma.

Geotrichum capitatum is a rare pathogen that causes opportunistic fungal infections in immunocompromised patients, particulary in patients with hematological malignancies. We report the case of a 72-year patient with polytrauma whose outcome was fatal. During his stay in the intensive care unit (ICU), he received a broad-spectrum antimicrobial therapy and underwent different invasive procedures. After becoming febrile on the 7th day of admission, two consecutive bronchoalveolar lavage (BAL) specimens were taken for microbiological analysis. The isolated species came as G. capitatum, that was identified using VITEK 2. Unfortunately, patient died before fungal identification, so the antifungal therapy wasn't administered. This case presentation emphasizes the importance of Geotrichum capitatum as an emerging fungal pathogen, as well as the significance of the predisponing factors that contributed to development of infection.

Prompt diagnosis and effective treatment of Trichosporon asahii catheter-related infection in non-immunocompromised neurosurgical patient.

Trichosporon asahii is a rare but emerging fungal pathogen that causes severe and life-threatening infections with high mortality rate, mostly in immunocompromised patients. It could be easily misdiagnosed due to lack of awareness, especially when invasive or deep-seated infections occur in non-immunocompromised patients, and inadequately treated since the clinical failures and high minimum inhibitory concentrations to some antifungal agents have been described. We present a case of T. asahii catheter-related infection in 66-year-old comatose patient with polytrauma, who was not immunodeficient, but was receiving broad-spectrum antibiotics for a long period. Due to prompt diagnosis and treatment which included catheter replacement and voriconazole, the patient successfully recovered from this infection. The aims of this case report were to highlight the importance of recognizing this otherwise colonizing yeast as potentially dangerous pathogen in non-immunocompromised patients with a long-term antibiotic therapy, and to emphasize the importance of the right therapeutic choice due to its resistance to certain antifungal agents.

Antimicrobial susceptibility of clinically isolated anaerobic bacteria in a University Hospital Centre Split, Croatia in 2013.

Anaerobic bacteria play a significant role in many endogenous polymicrobial infections. Since antimicrobial resistance among anaerobes has increased worldwide, it is useful to provide local susceptibility data to guide empirical therapy. The present study reports recent data on the susceptibility of clinically relevant anaerobes in a University Hospital Centre (UHC) Split, Croatia. A total of 63 Gram-negative and 59 Gram-positive anaerobic clinical isolates from various body sites were consecutively collected from January to December 2013. Antimicrobial susceptibility testing was performed using standardized methods and interpreted using EUCAST criteria. Patient's clinical and demographic data were recorded by clinical microbiologist. Among 35 isolates of Bacteroides spp., 97.1% were resistant to penicillin (PCN), 5.7% to amoxicillin/clavulanic acid (AMC), 8.6% to piperacillin/tazobactam (TZP), 29.0% to clindamycin (CLI) and 2.9% to metronidazole (MZ). Percentages of susceptible strains to imipenem (IPM), meropenem (MEM) and ertapenem (ETP) were 94.3. Resistance of other Gram-negative bacilli was 76.0% to PCN, 8.0% to AMC, 12.0% to TZP, 28.0% to CLI and 8% to MZ. All other Gram-negative strains were fully susceptible to MEM and ETP, while 96.0% were susceptible to IPM. Clostridium spp. isolates were 100% susceptible to all tested antibiotics except to CLI (two of four tested isolates were resistant). Propionibacterium spp. showed resistance to CLI in 4.3%, while 100% were resistant to MZ. Among other Gram-positive bacilli, 18.2% were resistant to PCN, 9.1% to CLI and 54.5% to MZ, while 81.8% of isolates were susceptible to carbapenems. Gram-positive cocci were 100% susceptible to all tested antimicrobials except to MZ, where 28.6% of resistant strains were recorded. Abdomen was the most common source of isolates (82.5%). The most prevalent types of infection were abscess (22.1%), sepsis (14.8%), appendicitis (13.9%) and peritonitis (6.6%). Twenty four patients (19.7%) received empiric antimicrobial therapy. One hundred and one patients (82.8%) had polymicrobial aerobic/anaerobic isolates cultivated from the same specimens. Almost all aerobic bacteria were of endogenous origin and showed fully susceptible antimicrobial profile; only 8.7% (9/104) were multiresistant and considered as hospital acquired. Based on our findings, ß-lactam/ß-lactamase inhibitor combinations and metronidazole remain useful antimicrobials for empiric treatment of anaerobic infections, while carbapenems should be reserved for situations were multidrug resistant, aerobic or facultative Gram-negative bacteria are expected. However, a certain percentage of resistant isolates were observed for each of these agents. Therefore, periodic resistance surveillance in anaerobes is highly recommended in order to guide empirical therapy.

First clinical and microbiological characterization of Clostridium difficile infection in a Croatian University Hospital.

Clinical background and molecular epidemiology of Clostridium difficile infection (CDI) in the University Hospital Centre Split were investigated from January 2010 to December 2011. In total, 54 patients with first episode of CDI were consecutively included in the study based on the positive EIA test specific for A and B toxins. Demographic and clinical data were prospectively analyzed from medical records. CDI incidence rate was 0.6 per 10,000 patient-days. Thirty six cases (70.6%) were healthcare-associated, twelve cases (23.5%) were community-associated and three (5.9%) were indeterminate. Six patients (11.7%) had suffered one or more recurrences and 37 patients (72.5%) showed severe CDI. Prior therapy with third generation cephalosporin was significantly associated with severe CDI (P<0.021). Fifty four toxigenic C. difficile strains were isolated and 50 of them were available for PCR-ribotyping. Sixteen different PCR-ribotypes were identified. The most prevalent were PCR-ribotype 001 (27.8%) and 014/020 (24.1%). Twenty three strains were resistant to at least one of the antibiotics tested. Among resistant strains, three (13.0%)--all PCR-ribotype 001--were multi-resistant. Resistance to fluoroquinolones was significantly higher in strains that caused infection after previous use of fluoroquinolones (P=0.04).

Monoclonal outbreak of VIM-1-carbapenemase-producing Enterobacter cloacae in intensive care unit, University Hospital Centre Split, Croatia.

Emergence of carbapenem-resistant Enterobacteriaceae has become a substantial global health problem. The aim of this study was to analyze carbapenem-resistant isolates of Enterobacter cloacae that have emerged for the first time in the intensive care unit (ICU) at the University Hospital Centre Split, Croatia. The strains were selected in the period between June and August 2012, according to their susceptibility patterns to carbapenems. Resistant isolates were screened for metallo-ß-lactamase (MBL) production with the use of the imipenem-EDTA disk synergy test, and positive findings were confirmed by PCR. The type of VIM ß-lactamase gene was determined by sequencing of PCR products. The genetic relatedness was evaluated using pulsed-field gel electrophoresis analysis. The demographic and clinical data were retrospectively analyzed from medical records. Five patients were infected and one patient was colonized with a single clone of multidrug-resistant VIM-1-producing E. cloacae susceptible only to colistin. Three cases of lower respiratory tract infections, one case of bacteremia, and one case of intra-abdominal infection were identified. All cases were hospital-acquired after prolonged stay in ICU. All patients had serious underlying diseases and received a broad-spectrum antibiotic. Four patients died and two had unimprovable medical condition at the time of discharge from the hospital. MBL-producing E. cloacae can cause fatal infection in severely ill patients. Monoclonal outbreak highlights the need for continuous surveillance and good infection control practices to prevent further spread since the antibiotic therapy options for infections caused by such strains are strongly limited.