Alarming spread of vancomycin resistant enterococci in Sweden since 2007.

The total number of persons infected or colonised with vancomycin-resistant enterococci mandatorily reported to the Swedish Institute for Infectious Disease Control increased dramatically during 2007 and 2008. During a period of twenty months from 1 July 2007 to 28 February 2009, a total of 760 cases were reported compared with 194 cases reported during the entire period from 2000 to 2006. This rise was mainly attributed to a wide dissemination of vancomycin resistant enterococci which started in a number of hospitals in Stockholm in the autumn of 2007 and was followed by dissemination in various healthcare facilities (hospitals and homes for the elderly) in a further two Swedish counties in 2008. The majority of the cases (97%) were acquired in Sweden and among these, healthcare-acquired E. faecium vanB dominated (n=634). The majority of these isolates had identical or closely related pulsed-field gel electrophoresis patterns indicating clonal dissemination in the affected counties. The median minimum inhibitory concentration of vancomycin was 32 mg/L (ranging from 4 to >128 mg/L) and of teichoplanin 0.12 mg/L (ranging from 0.06 to 0.25 mg/L). Particular emphasis was placed on countermeasures such as screening, contact tracing, cleaning procedures, education in accurate use of infection control practices as well as increasing awareness of hygiene among patients and visitors. With these measures the dissemination rate decreased substantially, but new infections with the E. faecium vanB strain were still detected.

Perceptions among Swedish hospital physicians on prescribing of antibiotics and antibiotic resistance.

OBJECTIVE: To explore and describe perceptions of antibiotic prescribing among Swedish hospital physicians, with special reference to whether the perceptions included awareness of antibiotic resistance (AR). DESIGN: A phenomenographic approach was used and data were collected in face-to-face interviews. SETTING: Hospitals in seven different counties in central Sweden. PARTICIPANTS: A strategic sample of 20 hospital physicians specialising in internal medicine, surgery or urology. MAIN OUTCOME: The variation of perceptions of antibiotic prescribing. RESULTS: Five qualitative different perceptions were found. AR was considered in two of the perceptions. Reasons for not considering AR included a dominating focus on the care of the patient combined with lack of focus on restrictive antibiotic use, or uncertainty about how to manage infectious diseases or the pressure from the healthcare organisation. Parallels between the five perceptions and the stages in the transtheoretical model of health behaviour change were seen. CONCLUSIONS: In three of the perceptions, AR was not considered when antibiotics were prescribed. Physicians who primarily express these three perceptions do not seem to be prepared to change to restrictive prescribing. Our findings can be useful in designing activities that encourage AR prevention. Organisational changes are also needed.

Sustained reduction of antibiotic use and low bacterial resistance: 10-year follow-up of the Swedish Strama programme.

Increasing use of antibiotics and the spread of resistant pneumococcal clones in the early 1990s alarmed the medical profession and medical authorities in Sweden. Strama (Swedish Strategic Programme for the Rational Use of Antimicrobial Agents and Surveillance of Resistance) was therefore started in 1994 to provide surveillance of antibiotic use and resistance, and to implement the rational use of antibiotics and development of new knowledge. Between 1995 and 2004, antibiotic use for outpatients decreased from 15.7 to 12.6 defined daily doses per 1000 inhabitants per day and from 536 to 410 prescriptions per 1000 inhabitants per year. The reduction was most prominent in children aged 5-14 years (52%) and for macrolides (65%). During this period, the number of hospital admissions for acute mastoiditis, rhinosinusitis, and quinsy (peritonsillar abscess) was stable or declining. Although the epidemic spread in southern Sweden of penicillin-resistant Streptococcus pneumoniae was curbed, the national frequency increased from 4% to 6%. Resistance remained low in most other bacterial species during this period. This multidisciplinary, coordinated programme has contributed to the reduction of antibiotic use without measurable negative consequences. However, antibiotic resistance in several bacterial species is slowly increasing, which has led to calls for continued sustained efforts to preserve the effectiveness of available antibiotics.

On the interaction between protein L and immunoglobulins of various mammalian species.

Protein L, a cell wall molecule of certain strains of the anaerobic bacterial species Peptostreptococcus magnus, shows high affinity for human immunoglobulin (Ig) light chains. In the present study protein L was tested against a panel of human myeloma proteins of the IgG, IgM, IgA and IgE classes, and strong binding was seen with antibodies carrying kappa light chains. A high degree of specificity for Ig was demonstrated in binding experiments with human plasma proteins. Apart from human Ig, strong protein L-binding activity was also detected in the serum of 12 out of 23 tested additional mammalian species, including other primates and rodents. Subsequent analysis with purified Ig samples demonstrated the binding of protein L to Ig of important laboratory animal species such as the mouse, the rat and the rabbit. The affinity constants for the interactions between protein L and polyclonal IgG of these species were 2.6 x 10(9), 3.9 x 10(8) and 7.4 x 10(7), respectively. In non-human species, the binding of protein L was also found to be mediated through Ig light chains, and the results demonstrate the potential value of protein L as an immunochemical tool.

Erythema nodosum--a manifestation of Chlamydia pneumoniae (strain TWAR) infection.

We describe 2 cases of erythema nodosum (EN) secondary to an infection with the TWAR strain of chlamydia, recently designated Chlamydia pneumoniae. Two young patients, 17 and 11 years old, were admitted with EN and no physical signs of pneumonia. One patient had a non-productive cough and fever. The other patient only ran a high fever. Chest radiography revealed bronchopneumonias. Infection with the C. pneumoniae species was proven by serologic testing using microimmunofluorescence technique. Serology and cultures for other bacteria known to induce EN were negative. Thus, C. pneumoniae (strain TWAR) can elicit EN.

Non-immune Fab- and Fc- mediated interactions of avian Ig with S. aureus and group C and G streptococci.

Serum samples from 19 avian species representing 8 orders were tested for their capacity to inhibit the Fab- and Fc-mediated immunoglobulin binding to protein A-carrying S. aureus and protein G-carrying group C and G streptococci. Four species (mallard, dunlin, starling and blackbird) belonging to three different orders showed a high degree of Fc-mediated protein A- and protein G-reactivity. Five species demonstrated a high level and nine species exhibited a low level of Fab-mediated protein A-reactivity. The four species identified as Fc-reactive were capable of Fab-mediated immunoglobulin binding with streptococcal surface proteins but incapable of Fab-mediated protein A binding. SDS-PAGE analysis confirmed that the protein A-Sepharose affinity purified material contained proteins corresponding to immunoglobulin chains. Inhibition results by avian sera were confirmed by direct binding of protein A-reactive proteins to bacteria, by precipitation in gel and by Western blot analysis of binding to protein A and protein G, respectively.

Streptococcal protein G has affinity for both Fab- and Fc-fragments of human IgG.

We have analyzed the binding of IgG and fragments of IgG [Fc, F(ab')2, and Fab] to group C and G streptococci and to protein G, the IgG binding cell wall protein of these bacteria. A direct correlation (r = 0.87, P less than 0.0001) was observed when the binding of radiolabelled, polyclonal IgG F(ab')2- and Fc-fragments to 23 group C and G streptococcal strains was compared. One strain (G-148) was treated with increasing amounts of pepsin, trypsin or papain and the Fab-binding structure was found to be much more sensitive to the enzymes as compared to the Fc-binding. A 35 K fragment of protein G was coupled to Sepharose, and both radiolabelled IgG F(ab')2- and Fc-fragments bound to the Sepharose beads. Binding of IgG fragments was inhibited by intact IgG or by the homologous IgG fragment, whereas Fc-fragments did not inhibit Fab binding or vice versa. Two radiolabelled protein G-fragments (28 and 35 K) showed different binding to polyclonal IgG, IgG F(ab')2-, IgG Fab- and IgG Fc-fragments. Thus, in a dot binding assay the 35 K fragment bound all IgG fragments tested, whereas the 28 K protein G fragment bound only intact IgG and IgG Fc-fragments. These results indicate two independent and separate binding sites for Fab- and Fc-fragments on protein G. Different binding sites on protein G were also indicated by Western blot analysis of four different protein G-fragments (28, 35, 42 and 65 K). In these experiments the 28 K fragment showed affinity only for Fc-fragments, while the higher mol. wt protein G preparations bound both IgG Fab- and Fc-fragments.

Magnetic resonance imaging in the diagnosis of spinal epidural abscess.

In 3 patients with epidural abscess, 2 in the cervical spine and 1 in the lumbar spine the definite diagnosis was established by magnetic resonance imaging (MR). In 1 patient computerized tomography was performed but the correct diagnosis was revealed only by MR. The infections were all acute and due to Staphylococcus aureus organisms. One patient developed a tetraparesis on the third day, before the diagnosis was established or antibiotic treatment initiated. The other 2 showed only minor and passing neurologic deficits. None was subjected to laminectomy. In 2 cases the diagnosis was confirmed by puncture. None of the patients had a preceding trauma or a known focus for the staphylococcal infection.

Non-immune F(ab')2- and Fc-mediated interactions of mammalian immunoglobulins with S. aureus and group C and G streptococci.

The distribution among mammalian species of non-immune F(ab')2- and Fc-mediated immunoglobulin interactions with surface proteins of S. aureus (protein A) and of group C and G streptococci was studied. Serum samples from 48 mammalian species representing 15 orders were first tested for their capacity to inhibit streptococcal F(ab')2-mediated binding; 26 of these sera were also tested for streptococcal IgG Fc-mediated binding. Analogous inhibition experiments were then carried out with staphylococci. All mammalian species studied inhibited both types of immunoglobulin binding to streptococci, viz the serum samples contained both F(ab')2- and Fc-reactive immunoglobulins. The reactivity was equal to that of human serum in 26 out of 47 mammalian sera. Seven sera showed a low degree of inhibition compared to human serum. The inhibiting capacities of the two streptococcal non-immune interactions showed a direct correlation (r = 0.91, p less than 0.0001 for the r-value) for individual species. The inhibition patterns observed with S. aureus differed from the profiles recorded with the streptococcal strains, suggesting that these organisms interact with separate sites on the immunoglobulin molecules. Isolated F(ab')2-binding was recorded in 5 out of 24 sera, and Fc-binding alone was noted in 7 sera. Taken together, the present studies demonstrate that mammalian immunoglobulins possess F(ab')2- and Fc-binding sites for protein A and for receptors on group C and G streptococci. The F(ab')2-mediated binding to streptococci is associated with Fc-reactivity, in contrast to protein A which may interact exclusively with a complementary structure in either the F(ab')2- or the Fc-portion of the immunoglobulins.

Two separate non-immune interactions between staphylococcal protein A and immunoglobulins are mediated by structures on gamma chains.

The present investigation was undertaken to determine whether the light or the heavy immunoglobulin chain is involved in the alternative, non-immune F(ab')2-mediated binding to staphylococcal protein A. Purified human polyclonal IgG was mildly reduced with dithiothreitol and alkylated with iodoacetamide. Intact IgG, purified light and heavy chains of polyclonal immunoglobulin G were tested in an inhibition assay for alternative non-immune F(ab')2-mediated binding to the protein A-carrying S. aureus, strain Cowan I. The IgG Fc-mediated binding to protein A was studied in parallel inhibition experiments. Heavy chains inhibited both the alternative F(ab')2- and the classical Fc-mediated binding to protein A. Isolated light chains were non-reactive. Intact IgG molecules were more potent inhibitors than isolated heavy chains tested in equimolar concentrations. Our results indicate that the alternative non-immune interaction between staphylococcal protein A and human immunoglobulins is mediated by structures expressed on the heavy immunoglobulin G chain. Thus, there are two separate protein A binding sites on gamma chains.

A non-immune interaction between the light chain of human immunoglobulin and a surface component of a Peptococcus magnus strain.

The immunoglobulin-binding capacity of a Peptococcus magnus strain was studied in a sensitive binding assay using purified human immunoglobulin preparations. The P. magnus strain 312 was capable of binding 48% of polyclonal IgG. Twenty-four of 40 purified myeloma proteins (60%) representing immunoglobulin classes A, G and M showed definite reactivity with an uptake level ranging from 45 to 90%. The remaining 16 monoclonal proteins were non-reactive, binding less than 15%. One myeloma protein with antistaphylolysin and two with antistreptolysin O specificity, i.e. monoclonal proteins with defined antigen specificity, were highly reactive. Binding capacity was observed in all four IgG subclasses and in Ig classes A and M. Twenty-three of 27 myeloma proteins of kappa type were reactive but only one of 13 myeloma proteins of lambda type interacted with the P. magnus strain. Isotope-labelled Fab gamma, F(ab')2 gamma and F(ab')2 alpha fragments were effectively bound by the strain. IgG Fc fragments were completely non-reactive. Isolated light immunoglobulin chains inhibited in a dose-dependent way the uptake of intact IgG to bacteria. Purified heavy chains were non-inhibitory. Isotope-labelled antistaphylolysin IgG F(ab')2 fragments preincubated with staphylolysin were as reactive as free antibody fragments, suggesting that the bacterial binding structure is located outside the antibody-combining site. The immunoglobulin reactivity of P. magnus was not affected by heating the bacteria to 80 degrees C for 5 min nor by treatment with trypsin or sodium metaperiodate. Digestion of 2 X 10(9) organisms with 100 micrograms of pepsin and papain reduced the binding by 58 and 90%, respectively. These data indicate that the binding of immunoglobulin to P. magnus is a non-immune reactivity mediated by a heat-stable surface protein interacting with specific sites on the light chain of the immunoglobulin molecule.

Non-immune IgG F(ab')2 binding to group C and G streptococci is mediated by structures on gamma chains.

The present investigation was designed to determine whether the heavy or the light immunoglobulin chain is involved in the non-immune binding of IgG F(ab')2 fragments to specific surface receptors on human group C and G streptococci. Purified human polyclonal IgG was mildly reduced with dithiothreitol and alkylated with iodoacetamide. Light (L) and heavy (H) chains were separated. Intact IgG and purified L and H chains of polyclonal immunoglobulin G were tested in an inhibition assay for non-immune IgG F(ab')2-mediated binding to group C and G streptococci. H chains inhibited the uptake of isotope-labelled IgG F(ab')2 fragments. Isolated L chains were non-reactive. Intact IgG molecules were more potent inhibitors than isolated H chains tested in equimolar concentrations. These results indicate that the non-immune interaction between human group C and G streptococci and F(ab')2 fragments of human IgG is mediated by reactive sites exposed on the immunoglobulin G H chains. The observation that intact IgG on a molar basis was more inhibitory than purified gamma chains suggests that the L chains may contribute to the reactivity, presumably by passive stabilization of the immunoglobulin molecule.

Alternative non-immune F(ab')2-mediated immunoglobulin binding to group C and G streptococci.

We tested 140 bacterial strains representing 19 different species for binding of purified radiolabelled F(ab')2 fragments prepared by pepsin digestion of polyclonal and monoclonal human IgG. Both polyclonal and monoclonal F(ab')2 fragments showed positive binding to group C and G streptococci with maximum uptake levels of 50% and 85%. Binding was obtained both with fresh bacteria and with organisms stabilized by heat treatment. F(ab')2 fragments of two human IgG1 myeloma proteins with anti-staphylolysin specificity showed a similar binding pattern. IgG present in normal human serum inhibited the uptake of F(ab')2 fragments, whereas albumin and fibrinogen and purified Fc fragments prepared by papain digestion of polyclonal IgG and monoclonal IgG1 did not show such capacity. Fourteen human myeloma proteins representing IgA, IgM and the four IgG subclasses were tested for inhibiting capacity. Reactivity was noted with at least one myeloma protein within each IgG subclass but not with IgA or with IgM monoclonal proteins. Normal rabbit serum was as inhibitory as normal human serum, whereas dog serum was less reactive. These data demonstrate that group C and G streptococci carry a heat-stable surface component interacting with the F(ab')2 portion of the IgG molecule. The results suggest that the reactive site on the immunoglobulin molecule may reside in the more constant part of the variable domain. This new reactivity is different from the previously known non-immune reaction involving the IgG Fc portion. This alternative non-immune reactivity is analogous to but distinct from the alternative protein A reaction in Staphylococcus aureus.