Antibiotic use in pre-school children and the correlation with adult educational levels in two Nordic counties: a replication of a 20-year-old study.

OBJECTIVE: The aim of this study was to describe the change of antibiotic prescribing in pre-school children in the municipalities of the former Copenhagen County in Denmark and Skåne County in Sweden after 20 years of antibiotic stewardship effort. Furthermore, the variation in the prescribing of antibiotics between the municipalities and the correlation between municipal adult educational level and antibiotic prescribing in pre-school children was assessed. METHODS: In this ecological study, information on antibiotic prescribing in pre-school children was obtained from a central pharmacy settlement system in each Region. The antibiotic prescribing rate was expressed in defined daily doses per 1,000 inhabitants per day (DDD/TID) and number of prescriptions/1000 inhabitants. Information on municipal adult educational levels was obtained from Statistics Denmark and Statistics Sweden. RESULTS: The antibiotic prescribing rate during 2017 was higher in the municipalities of Copenhagen County (5.6-7.9 DDD/TID) compared to the municipalities of Skåne County (4.2-6.6 DDD/TID). In 1998 a higher rate was found in Skåne County (9.6-17.7 DDD/TID) compared to Copenhagen County (8.0-12.9 DDD/TID). A non-significant negative correlation between adult educational levels and antibiotic prescribing was observed in the municipalities of Copenhagen County (r= -0.233, p = .352) while the correlation was positive in the municipalities of Skåne County (r= +0.410, p = .018). The same correlations were observed in 1998. CONCLUSION: We found higher antibiotic prescribing in pre-school children in the municipalities of Copenhagen County compared to Skåne County in 2017, suggesting a possible overuse of antibiotics in Denmark. Further research should try to elucidate the reasons for the observed variation.

Uncomplicated urinary tract infection in primary health care: presentation and clinical outcome.

BACKGROUND: Uncomplicated urinary tract infection (UTI) causes bothersome symptoms among women and is a leading cause for antibiotic prescribing in primary healthcare (PHC). METHODS: A prospective observational study in eight different PHC centres in Sweden including 192 women with symptoms of uncomplicated UTI. Questionnaires and symptom diaries were used to retrieve patient data. All urine samples were analysed with urine culture and susceptibility testing. The aim was to describe the clinical presentation of symptoms in uncomplicated UTI in relation to bacterial findings in urine and to describe the course and duration of symptoms in relation to anamnestic factors, bacterial findings and antibiotic treatment. RESULTS: Median symptom duration before seeking care was four days (IQR 1-7). Restrictions in daily life related to symptoms of uncomplicated UTI were reported by the majority (74%) of respondents. The median number of days concerning any symptom after consultation was 4.0 days (IQR 2.0-5.0) for patients treated with antibiotics, and 6.5 days (IQR 3.0-10.0) for patients not treated with antibiotics. There was an association between longer symptom duration after consultation and age over 50 years, relative risk (RR) 1.76 (95% CI 1.25-2.49). Antibiotic treatment RR 0.47 (95% CI 0.27-0.81) was associated with reported shorter duration of symptoms. CONCLUSIONS: Women visiting primary health care with symptoms indicating uncomplicated UTI have symptoms for several days before seeking care and after consulting. A majority of patients feel restricted in their daily activities due to uncomplicated UTI. Older women and women not treated with antibiotics have the longest symptom duration after consultation.

Different antibiotic regimes in men diagnosed with lower urinary tract infection - a retrospective register-based study.

OBJECTIVE: To compare the proportion of therapy failure, recurrence and complications within 30 days after consultation between men diagnosed with lower urinary tract infection (UTI) treated with narrow-spectrum antibiotics (nitrofurantoin or pivmecillinam) and broad-spectrum antibiotics (fluoroquinolones or trimethoprim or trimethoprim/sulfamethoxazole). DESIGN: A retrospective cohort study based on data derived from electronic medical records between January 2012 and December 2015. SETTING: Primary health care and hospital care in five different counties in Sweden. Patients: A total of 16,555 men aged between 18 and 79 years diagnosed with lower UTI. MAIN OUTCOME MEASURES: Treatment with narrow-spectrum antibiotics was compared with broad-spectrum antibiotics regarding therapy failure, recurrence and complications within 30 days. RESULTS: The median age of included men was 65 IQR (51-72) years. Narrow-spectrum antibiotics were prescribed in 8457 (40%) and broad-spectrum antibiotics in 12,667 (60%) cases, respectively. Therapy failure was registered in 192 (0.9%), recurrence in 1277 (6%) and complications in 121 (0.6%) cases. Therapy failure and recurrence were more common in patients treated with narrow-spectrum antibiotics and trimethoprim (p < 0.001), but no such difference could be detected regarding complications. CONCLUSION: There was no difference in incidence of complications within 30 days between men treated with narrow- or broad-spectrum antibiotics. Patients prescribed broad-spectrum antibiotics had lower odds of reconsultation because of therapy failure and recurrence. From current data, treatment with narrow-spectrum antibiotics seems to be an optimal choice regarding preventing complications when treating men with lower UTI. KEY POINTS Complications such as pyelonephritis and sepsis are uncommon in men diagnosed with lower urinary tract infection treated with antibiotics. There was no difference in incidence of complications among men diagnosed with lower urinary tract infection treated with narrow- or broad-spectrum antibiotics. In spite of higher incidence of therapy failure and recurrence, treatment with narrow-spectrum antibiotics seems to be an optimal choice regarding preventing complications when treating men diagnosed with lower UTI.

Antibiotic-prescribing and antibiotic-resistance patterns among elderly citizens residing in two Nordic regions.

Objective: The objective of this study was to compare antibiotic-prescribing rates in 2016 and antibiotic-resistance rates in 2017 among citizens aged ≥85 years between the Capital Region in Denmark and the Skåne Region in Sweden, with regards to overall antibiotic use and antibiotics of choice for urinary tract infections (UTIs) and skin and soft tissue infections (SSTIs). Methods: Inhabitants ≥85 year old on the date of prescription during 2016 and residing in the Capital Region or the Skåne Region were included for antibiotic-prescription analyses. Samples from 2017 from residents of the same regions who were ≥85 years old were included for antibiotic-resistance analyses. Antimicrobial use was determined according to the drugs of choice for UTIs and SSTIs in Denmark and Sweden. Students t-tests were used to compare antibiotic prescribing while a Chi-Squared test was performed to compare antibiotic resistance. Results: There was a significantly higher overall prescription rate among citizens ≥85 years in the Capital Region than in the Skåne Region. The same pattern was evident for the antibiotics of choice for UTIs and SSTIs except for clindamycin. Antibiotic resistance against all antibiotics included was more prominent in the Capital Region than in the Skåne Region. Conclusion: Considerable variation in antibiotic prescribing and resistance exists among elderly citizens between these two adjacent Nordic regions. Information and reflection on current practices and resistance patterns may direct attention towards antimicrobial stewardship as a higher priority and may help inform and motivate prescribing behaviours.

Increased adherence to treatment guidelines in patients with urinary tract infection in primary care: A retrospective study.

BACKGROUND: Urinary tract infection (UTI) is common in primary care and leads to a high number of antibiotic prescriptions. Antimicrobial resistance is a global health problem; better antimicrobial prescribing is one way to limit antimicrobial resistance. We aimed to describe the number of consultations for patients diagnosed with lower urinary tract infection (LUTI) and pyelonephritis and changes in prescribing of antibiotics to men and women with LUTI and pyelonephritis in Swedish PHC between the years 2008 and 2013. METHODS: We performed a descriptive study of changes in UTI diagnosis and antibiotic prescribing in UTI for the years 2008, 2010 and 2013. The Primary Care Record of Infections in Sweden, a database regarding diagnosis linked antibiotic prescribing in primary care, was analyzed concerning data for men and women of all ages regarding UTI visits and antibiotic prescribing. The results were analyzed in relation to current national guidelines. RESULTS: There was a variability in consultation incidence for LUTI with an increase between 2008 and 2010 and a decrease between 2010 and 2013, resulting in a slight rise in consultation incidence between 2008 and 2013. The use of recommended nitrofurantoin or pivmecillinam in LUTI in women increased from 54% in 2008 to 69% in 2013. Fluoroquinolones or trimethoprim were prescribed in 24% of LUTI cases in women in 2008 and in 7% of cases in 2013. Prescriptions of pivmecillinam or nitrofurantoin in male LUTI cases increased from 13% in 2008 to 31% in 2013. Fluoroquinolones or trimethoprim were prescribed in 54% of male LUTI cases in 2008 and 32% in 2013. CONCLUSIONS: Swedish GPs seem to follow national guidelines in the treatment of LUTI in women. In male LUTI cases, the prescriptions of fluoroquinolones remain high and further research is needed to follow prescription patterns and enhance more prudent prescribing to this group of patients.

Uncomplicated urinary tract infections in Swedish primary care; etiology, resistance and treatment.

BACKGROUND: Uncomplicated urinary tract infection (uUTI) is common and a majority of patients are prescribed antibiotics. There is little knowledge about antibiotic resistance in urine samples from patients with uUTI in primary health care (PHC). The aim was to describe antibiotic treatment, bacterial findings, the prevalence of resistant E.coli and factors associated with antibiotic resistance. The aim was also to compare the prevalence of resistant E.coli in clinical practice with the prevalence of resistant E.coli in routine microbiological laboratory data. METHODS: This observational study in PHC setting started in November 2014 and ended in March 2016. Women aged 17 years and older with symptoms indicating uUTI from eight PHCs were included. Questionnaires were used to retrieve anamnestic data. All urine samples were sent to the local laboratory of microbiology for diagnostic analysis and susceptibility testing. Proportions of resistant E.coli were compared with corresponding data from the regional laboratory. RESULTS: Urine cultures were analysed in 304 women with a median age of 46 (IQR 32-66) years. Bacterial growth was found in 243 (80%) of urine samples, and E.coli in 72% of the positive samples. A total of 80% of detected E.coli isolates were susceptible to all tested antimicrobials and resistance rates to ciprofloxacin were lower than reported from the local clinical laboratory. Antibiotic treatment within the last year was independently associated with antibiotic resistant E.coli in the urine sample adjusted OR 4.97 (95% CI 2.04-12.06). A total of 74% of the women were treated with antibiotics. The most prescribed was pivmecillinam followed by nitrofurantoin. CONCLUSIONS: Antibiotic resistance in E.coli was low. Antibiotic treatment within the last year was associated with antibiotic resistant E.coli. Data from the clinical microbiology laboratory indicates that laboratory data may overestimate antibiotic resistance and lead to an unnecessary change in empiric antibiotic treatment of uUTI in primary care. The empirically prescribed antibiotics, were inline with Swedish treatment recommendations for uUTI.

Comparison of antibiotic prescribing and antimicrobial resistance in urinary tract infections at the municipal level among women in two Nordic regions.

Objectives: To describe and compare the prescribing of antibiotics used for urinary tract infections and its correlation with resistance in Escherichia coli in urinary samples across two adjacent regions-the Capital Region and the Skaane Region-and their municipalities in Denmark and Sweden. Methods: The Capital Region consists of 29 municipalities and 725 960 female inhabitants aged ≥18 years and the Skaane Region consists of 33 municipalities and 515 668 female inhabitants aged ≥18 years. Aggregated data from outpatient care on the prescribing of pivmecillinam, trimethoprim and nitrofurantoin from both regions were analysed. The Department of Clinical Microbiology in both regions provided data on E. coli resistance in urinary samples from women aged ≥18 years. Data were measured as the number of prescriptions/1000 women/year, number of DDDs/1000 women/year and DDDs/prescription. Correlation analyses between antibiotic prescribing and antibiotic resistance rates were performed. Results: Antibiotic prescribing and resistance rates were significantly higher in the Capital Region compared with the Skaane Region. Large variations in prescription and resistance rates were found at the municipal level, but there were no correlations between the antibiotic prescription and resistance rates when each region was analysed separately. Conclusions: Although closely related, there are large differences in antibiotic prescribing and antibiotic resistance. It is suggested that the regional guidelines are an important driver and explanatory factor for the variations; however, further research is needed in this new field and factors such as the influence of cultural aspects should be the target of further research.

Eradication of methicillin-resistant Staphylococcus aureus (MRSA) throat carriage: a randomised trial comparing topical treatment with rifampicin-based systemic therapy.

Eradication of methicillin-resistant Staphylococcus aureus (MRSA) colonisation may prevent transmission of strains between patients and reduces the risk of clinical infection. Colonisation of the throat is associated with prolonged carriage and is more difficult to eradicate. An open randomised study was conducted to evaluate two eradication protocols. Patients with pharyngeal carriage of MRSA were enrolled at six Swedish centres during 4 years. One treatment group received oral rifampicin and either clindamycin or trimethoprim/sulfamethoxazole (SXT) for 7 days in combination with nasal mupirocin. Patients in the other group were treated with nasal mupirocin only. Patients in the same household were randomised together. Both groups followed a hygiene protocol including chlorhexidine washing. Cultures from the nares, perineum and throat were taken at baseline and then at 2 weeks, 2 months and 6 months after the end of treatment. A total of 28 patients received rifampicin-based systemic antibiotics and 24 subjects received mupirocin only. At follow-up 6 months after the end of treatment, 61% of patients and 50% of households in the systemic antibiotics group had culture results negative for MRSA. Significantly less patients (12%) and households (10%) became decolonised in the group receiving topical treatment only. A combination of rifampicin and either clindamycin or SXT was more effective in eliminating pharyngeal MRSA carriage compared with topical treatment with mupirocin only.

Children with respiratory tract infections in Swedish primary care; prevalence of antibiotic resistance in common respiratory tract pathogens and relation to antibiotic consumption.

BACKGROUND: The majority of antibiotics consumed in developed countries are prescribed in primary care. However, little is known about resistance levels in the primary care population. METHOD: Nasopharyngeal cultures were obtained from children, 0-10 years of age, seeking care at their Primary Health Care Centre with symptoms of respiratory tract infection. Parental questionnaires were used to retrieve information about the child's previous antibiotic consumption. RESULT: Cultures from 340 children were gathered. The level of resistant Haemophilus influenzae was low and the prevalence of penicillin non-susceptible pneumococci (PNSP MIC ≥ 0.125 mg/L) was 6% compared to 10% (p = 0.31) in corresponding cultures from children diagnosed at the local clinical microbiology laboratory. Antibiotic treatment within the previous 4 weeks predisposed for resistant bacteria in the nasopharynx, OR: 3.08, CI 95% (1.13-8.42). CONCLUSION: Low prevalence of PNSP supports the use of phenoxymethylpenicillin as empirical treatment for childhood upper respiratory tract infections attending primary care in our setting. It is important that studies on resistance are performed in primary care populations to evaluate data from microbiological laboratories. Recent antibiotic treatment increases risk of bacterial resistance in children and continuous work to reduce unnecessary antibiotic prescribing should be prioritised.

Reduction in antibiotic prescribing for respiratory tract infections in Swedish primary care- a retrospective study of electronic patient records.

BACKGROUND: Swedish studies on antibiotic use in primary care have been based on one-week registrations of infections. In order to study adherence to guidelines, analyses based on large databases that provide information on diagnosis linked prescriptions, are needed. This study describes trends in management of infections in Swedish primary care particularly with regards to antibiotic prescribing and adherence to national guidelines. METHODS: A descriptive study of Sweden's largest database regarding diagnosis linked antibiotic prescription data, the Primary care Record of Infections in Sweden (PRIS), for the years 2008, 2010 and 2013. RESULTS: Although the consultation rate for all infections remained around 30% each year, antibiotic prescribing rates decreased significantly over the years from 53.7% in 2008, to 45.5% in 2010, to 38.6% in 2013 (p = .032). The antibiotic prescribing rate for respiratory tract infections (RTIs) decreased from 40.5% in 2008 to 24.9% in 2013 while those for urinary tract infections and skin and soft tissue infections were unchanged. For most RTI diagnoses there was a decrease in prescription rate from 2008 to 2013, particularly for the age group 0-6 years. Phenoxymethylpenicillin (PcV) was the antibiotic most often prescribed, followed by tetracycline. Tonsillitis and acute otitis media were the two RTI diagnoses with the highest number of prescriptions per 1000 patient years (PY). For these diagnoses an increase in adherence to national guidelines was seen, with regards to treatment frequency, choice of antibiotics and use of rapid antigen detection test. The frequency in antibiotic prescribing varied greatly between different Primary Healthcare Centres (PHCCs). CONCLUSION: Falling numbers of consultations and decreased antibiotic prescription rates for RTIs have reduced the antibiotic use in Swedish primary care substantially. Overprescribing of antibiotics could still be suspected due to large variability in prescribing frequency, especially for acute bronchitis and sinusitis. Continuous evaluation of diagnosis linked prescribing data and feedback to doctors is essential in order to achieve a more prudent antibiotic use.

An Audit-Based, Infectious Disease Specialist-Guided Antimicrobial Stewardship Program Profoundly Reduced Antibiotic Use Without Negatively Affecting Patient Outcomes.

Background. Antimicrobial stewardship programs are increasingly implemented in hospital care. They aim to simultaneously optimize outcomes for individual patients with infections and reduce financial and health-associated costs of overuse of antibiotics. Few studies have examined the effects of antimicrobial stewardship programs in settings with low proportions of antimicrobial resistance, such as in Sweden. Methods. An antimicrobial stewardship program was introduced during 5 months of 2013 in a department of internal medicine in southern Sweden. The intervention consisted of audits twice weekly on all patients given antibiotic treatment. The intervention period was compared with a historical control consisting of patients treated with antibiotics in the same wards in 2012. Studied outcome variables included 28-day mortality and readmission, length of hospital stay, and use of antibiotics. Results. A reduction of 27% in total antibiotic use (2387 days of any antibiotic) was observed in the intervention period compared with the control period. The reduction was due to fewer patients started on antibiotics as well as to significantly shorter durations of antibiotic courses (P < .001). An earlier switch to oral therapy and a specific reduction in use of third-generation cephalosporins and fluoroquinolones was also evident. Mortality, total readmissions, and lengths of stay in hospital were unchanged compared with the control period, whereas readmissions due to a nonresolved infection were fewer during the intervention of 2013. Conclusions. This study demonstrates that an infectious disease specialist-guided antimicrobial stewardship program can profoundly reduce antibiotic use in a low-resistance setting with no negative effect on patient outcome.

Prevalence of penicillin-non-susceptible Streptococcus pneumoniae in children in day-care centres subjected to an intervention to prevent dispersion.

BACKGROUND: The aim of this study was to evaluate the day-care interventions implemented in southern Sweden to restrict the dispersion of penicillin-non-susceptible pneumococci with a minimum inhibitory concentration of penicillin G of at least 0.5 mg/l (PNSP0.5). METHODS: A retrospective epidemiological study was performed and data from 109 day-care centre interventions from 2000 to 2010 were analysed, including screening results from 7157 individuals. RESULTS: It was found that 42% of the children were carriers of pneumococci and 5% of the screened children were PNSP0.5 carriers. Very few personnel were PNSP0.5 carriers and they were carriers for only a short time. Significantly more contact cases with the same serogroup as the index case were found in the first screening and in the same department as the index case, but a substantial number of contact cases were found in adjacent departments. CONCLUSIONS: Screening of personnel is not worth the effort. Based on our results, procedures to restrict dispersion of PNSP0.5 in day-care centres could be improved. To find the majority of contact cases with PNSP0.5 an early screening including adjacent departments seems to be the best approach.

Efficacy of a once-a-week screening programme to control extended-spectrum beta-lactamase-producing bacteria in a neonatal intensive care unit.

BACKGROUND: Extended-spectrum beta-lactamase (ESBL)-producing bacteria are an escalating problem threatening health. Devastating consequences can result in neonatal intensive care units (NICU) due to these bacteria. The aim of this study was to investigate the efficacy of once-a-week screening (July 2010 to September 2012) versus screening on demand (April 2008 to June 2010). MATERIALS AND METHODS: The investigation was an open retrospective descriptive study comparing 2 unpaired groups, the first exposed to screening on demand and the second to screening once a week. All other infection control measures were unchanged. Both groups were cared for in the NICU of Skåne University Hospital. Parameters compared were the proportion of cultured neonates, prevalence, time before detection, number of secondary cases, and clinical infections due to ESBL-producing bacteria. RESULTS: The proportion of cultured neonates increased from 28% to 49% (p < 0.05) in period 2. The time from admission to detection was 8 days shorter in period 2 (p < 0.05). Secondary cases decreased from 44% to 9% (p < 0.05), and clinical infections from 4 to 0 cases (p < 0.05). During period 2, the prevalence of colonization was 1.77%. CONCLUSIONS: Once-a-week screening is a strategy to control the epidemiology of unwanted pathogens among newborn infants. It provides the opportunity for early intervention, thereby avoiding secondary cases and infections. Premature neonates in particular benefit from this approach. The prevalence of ESBL of 1.77% is low from an international perspective. ESBL appear to be introduced onto the ward by mothers colonized with ESBL.

Risk factors for pneumococcal carriage in day care centers: a retrospective study during a 10-year period.

In this retrospective epidemiologic study, we present pneumococcal carriage data from 109 Swedish day care centers over a period of 10 years. Aspects of season, age, personnel and group size were studied. We found a significant seasonal variation in pneumococcal carriage. Group size was a significant risk factor for pneumococcal carriage. Pneumococcal carriage was 4.5 % in personnel.

Risk factors for infections with extended-spectrum beta-lactamase-producing Escherichia coli in a county of Southern Sweden.

BACKGROUND: It is important to identify patients who are at risk for infections with extended-spectrum ß-lactamase (ESBL)-producing bacteria in order to reduce mortality, to avoid spread of resistant bacteria in hospitals, and to minimize the number of patients receiving unnecessary treatment with broad-spectrum antibiotics. A case-control survey among Swedish patients was performed at Skåne University Hospital to identify risk factors for developing an infection with ESBL-producing Escherichia coli in a low endemic country. METHODS: We used a computerized database to identify patients with growth of ESBL-producing E. coli (n = 109) in urine or blood cultures and an equal number of controls matched for age and gender with non ESBL-producing E. coli in urine and blood diagnosed between January and October 2008. We used unadjusted P-values. RESULTS: Patients with ESBL-producing E. coli had a significantly (P < 0.05) higher likelihood of having traveled to Asia including Turkey and the Middle East including Egypt (14/58) than the non-ESBL-positive group (4/53). Hospital stay during the previous year (P < 0.04), especially for more than one month, was another significant (P = 0.01) risk factor for infection with ESBL-producing E. coli (8/58). A stay in the surgical department was a further risk factor (P < 0.01). CONCLUSION: In this study, we identified 22 of 58 (38%) patients with ESBL-producing E. coli by considered significant risk factors before starting antibiotics.

Theory-based interventions to reduce prescription of antibiotics--a randomized controlled trial in Sweden.

BACKGROUND: Upper respiratory tract infections (URTIs) are the most common reason for consulting a GP and for receiving an antibiotic prescription, although evidence shows poor benefit but rather increasing antibiotic resistance. Interventions addressing physicians have to take into consideration the complexity of prescribing behaviour. OBJECTIVE: To study whether interventions based on behavioural theories can reduce the prescribing of antibiotics against URTIs in primary care. Setting and subjects. GPs at 19 public primary health care centres in southern Sweden. METHODS: We performed a randomized controlled study using two behavioural theory-based interventions, the persuasive communication intervention (PCI) and the graded task intervention (GTI), which emerged from social cognitive theory and operant learning theory. GPs were randomized to a control group or one of two intervention groups (PCI and GTI). MAIN OUTCOME MEASURES: Changes in the rate of prescription of antibiotics against URTIs in primary care patients of all ages and in patients aged 0-6 years. RESULTS: No significant differences were seen in the prescription rates before and after the interventions when patients of all ages were analysed together. However, for patients aged 0-6 years, there was a significant lower prescription rate in the PCI group (P = 0.037), but not the GTI group, after intervention. CONCLUSION: Theory-based interventions have limited impact on reducing the prescription of antibiotics against URTIs in primary care. Future studies are needed to draw firm conclusions about their effects.

Prevalence of extended-spectrum beta-lactamase-producing bacteria in food.

Extended-spectrum ß-lactamase (ESBL)-producing Enterobacteriaceae with Cefotaximase-München (CTX-M) enzymes are rapidly increasing worldwide and pose a threat to health care. ESBLs with CTX-M enzymes have been isolated from animals and different food products, but it is unknown if food imported from the Mediterranean area may be a possible reservoir of these bacteria. During 2007-2008, swab samples from food across different retail outlets (mostly food from the Mediterranean countries and Swedish chicken) were collected. Escherichia coli strains from Swedish meat and E. coli isolates from unspecified food from a Swedish food testing laboratory were also examined. In 349 of the 419 swab samples, growth of Enterobacteriaceae was found. In most of the samples, there was also growth of Gram-negative environmental bacteria. Air dry-cured products contained significantly less Enterobacteriaceae isolates compared to lettuces; however, none of the examined Enterobacteriaceae harbored ESBLs. This study did not support the theory that imported food from the Mediterranean area or Swedish domestic food might constitute an important vehicle for the dissemination of ESBL-producing Enterobacteriaceae; however, a spread from food to humans may have occurred after 2008.

Increase of ß-lactam-resistant invasive Haemophilus influenzae in Sweden, 1997 to 2010.

The proportions of Haemophilus influenzae resistant to ampicillin and other ß-lactam antibiotics have been low in Sweden compared to other countries in the Western world. However, a near-doubled proportion of nasopharyngeal Swedish H. influenzae isolates with resistance to ß-lactams has been observed in the last decade. In the present study, the epidemiology and mechanisms of antimicrobial resistance of H. influenzae isolates from blood and cerebrospinal fluid in southern Sweden from 1997 to 2010 (n = 465) were studied. Antimicrobial susceptibility testing was performed using disk diffusion, and isolates with resistance to any tested ß-lactam were further analyzed in detail. We identified a significantly increased (P = 0.03) proportion of ß-lactam-resistant invasive H. influenzae during the study period, which was mainly attributed to a significant recent increase of ß-lactamase-negative ß-lactam-resistant isolates (P = 0.04). Furthermore, invasive ß-lactamase-negative ß-lactam-resistant H. influenzae isolates from 2007 and onwards were found in higher proportions than the corresponding proportions of nasopharyngeal isolates in a national survey. Multiple-locus sequence typing (MLST) of this group of isolates did not completely separate isolates with different resistance phenotypes. However, one cluster of ß-lactamase-negative ampicillin-resistant (BLNAR) isolates was identified, and it included isolates from all geographical areas. A truncated variant of a ß-lactamase gene with a promoter deletion, bla(TEM-1)-PΔ dominated among the ß-lactamase-positive H. influenzae isolates. Our results show that the proportions of ß-lactam-resistant invasive H. influenzae have increased in Sweden in the last decade.

Duration of colonization with extended-spectrum beta-lactamase-producing Escherichia coli in patients with travellers' diarrhoea.

BACKGROUND: Resistant Enterobacteriaceae have become a worldwide epidemic during the last decade and are a great threat to health care worldwide. International travel is a major risk factor for becoming colonized with extended-spectrum beta-lactamase (ESBL)-producing bacteria. Data on the persistence of colonization with ESBL-producing bacteria in the faecal flora are limited. METHODS: A prospective cohort study was performed between October 2007 and October 2010. Fifty-eight patients with faecal carriage of ESBL-producing Escherichia coli from a previous study of patients with travellers' diarrhoea were included. RESULTS: Forty-one of the patients had a complete follow-up. Ten of these patients (24%) carried ESBL-producing E. coli at the first follow-up point (3-8 months), of whom 4 had a new ESBL strain. At the 3-y follow-up, 4 patients carried ESBL (10%), of whom 1 had 2 new ESBL strains. CONCLUSIONS: The long duration of ESBL carriage is worrisome. These carriers may be an important source of the spread of ESBLs in the population and this has implications for the clinical management of patients.