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BACKGROUND: We aimed to determine the noninferiority of fosfomycin compared to ciprofloxacin as an oral step-down treatment for Escherichia coli febrile urinary tract infections (fUTIs) in women. METHODS: This was a double-blind, randomized, controlled trial in 15 Dutch hospitals. Adult women who were receiving 2-5 days of empirical intravenous antimicrobials for E. coli fUTI were assigned to step-down treatment with once-daily 3g fosfomycin or twice-daily 0.5g ciprofloxacin for 10 days of total antibiotic treatment. For the primary end point, clinical cure at days 6-10 post-end of treatment (PET), a noninferiority margin of 10% was chosen. The trial was registered on Trialregister.nl (NTR6449). RESULTS: After enrollment of 97 patients between 2017 and 2020, the trial ended prematurely because of the coronavirus disease 2019 pandemic. The primary end point was met in 36 of 48 patients (75.0%) assigned to fosfomycin and 30 of 46 patients (65.2%) assigned to ciprofloxacin (risk difference [RD], 9.6%; 95% confidence interval [CI]: -8.8% to 28.0%). In patients assigned to fosfomycin and ciprofloxacin, microbiological cure at days 6-10 PET occurred in 29 of 37 (78.4%) and 33 of 35 (94.3%; RD, -16.2%; 95% CI: -32.7 to -0.0%). Any gastrointestinal adverse event was reported in 25 of 48 (52.1%) and 14 of 46 (30.4%) patients (RD, 20.8%; 95% CI: 1.6% to 40.0%), respectively. CONCLUSIONS: Fosfomycin is noninferior to ciprofloxacin as oral step-down treatment for fUTI caused by E. coli in women. Fosfomycin use is associated with more gastrointestinal events. CLINICAL TRIAL REGISTRATION: Trial NL6275 (NTR6449).
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COVID-19 , Infecciones por Escherichia coli , Fosfomicina , Infecciones Urinarias , Adulto , Antibacterianos/efectos adversos , Ciprofloxacina/uso terapéutico , Método Doble Ciego , Escherichia coli , Infecciones por Escherichia coli/complicaciones , Infecciones por Escherichia coli/tratamiento farmacológico , Femenino , Fiebre/tratamiento farmacológico , Fosfomicina/efectos adversos , Humanos , Infecciones Urinarias/microbiologíaRESUMEN
BACKGROUND: Total knee arthroplasty (TKA) provides successful results in most patients. Periprosthetic joint infection (PJI) accounts for up to 25% of failed TKAs needing revision. In clinical practice, consensus in diagnostic strategy for excluding or diagnosing PJI is still lacking. In this systematic review and meta-analysis, we aim to provide a simplified data-driven diagnostic strategy for aseptic knee and hip revision surgeons to rule out PJI in the outpatient clinic phase. METHODS: A literature search in EMBASE, MEDLINE, PubMed, and Cochrane was conducted. Studies involving the diagnosis of PJI in patients with failed TKAs and total hip arthroplasties needing revision were identified. Only studies using the Musculoskeletal Infection Society criteria were included. Quality was assessed using MINORS criteria. Meta-analysis was performed for each diagnostic test identified in the included studies. Pooled estimates of diagnostic accuracy measures were calculated using a bivariate model and plotted in summary receiver-operator characteristic curves. Positive and negative predictive values were calculated in a hypothetical sample of patients with a given disease prevalence. RESULTS: Twenty-four studies met the inclusion criteria, describing a total of 2974 patients. Quality scores ranged from 13 to 19. Meta-analysis could be performed on 7 unique diagnostic tests. Highest pooled sensitivity and specificity were demonstrated for α-defensin with values of 86% and 96.6%, respectively. α-defensin and white blood cell count in synovial fluid demonstrate highest negative predictive value values. CONCLUSIONS: We recommend, in a clinical setting with low-intermediate prevalence of PJI, performing arthrocentesis and joint fluid analysis using α-defensin and/or white blood cell count before revision TKA and revision total hip arthroplasty surgery to rule out PJI.
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Artritis Infecciosa , Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Infecciones Relacionadas con Prótesis , alfa-Defensinas , Artritis Infecciosa/cirugía , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Biomarcadores , Humanos , Infecciones Relacionadas con Prótesis/cirugía , Sensibilidad y Especificidad , Líquido Sinovial/química , alfa-Defensinas/análisisRESUMEN
We designed a study to describe the characteristics of sequence type 131 (ST131) lineages, including the H30-Rx sublineage, among a global collection of extended-spectrum ß-lactamase (ESBL)-producing Escherichia coli isolates from 9 countries collected from 2000 to 2011. A total of 240 nonrepeat isolates from Canada, the United States, Brazil, the Netherlands, France, the United Arab Emirates (UAE), India, South Africa, and New Zealand were included. Established PCR, sequencing, and typing methods were used to define ST131 lineages, H30 and H30-Rx phylogenetic groups, gyrA and parC mutations, virotypes, and plasmid-mediated quinolone resistance determinants. The majority of the isolates produced CTX-M-15 with aac(6')-lb-cr, belonged to phylogenetic group B2, and were positive for the H30 lineage with the gyrA1AB and parC1aAB mutations. ST131 showed 15 distinct pulsotypes; 43% of the isolates belonged to four pulsotypes, with a global distribution. Seventy-five percent of the ST131 isolates belonged to H30-Rx; this sublineage was present in all the countries and was associated with multidrug resistance, blaCTX-M-15, aac(6')-lb-cr, and virotypes A and C. The H41 lineage was negative for the ST131 pabB allele-specific PCR. The multidrug-resistant H30-Rx sublineage poses an important public health threat due to its global distribution, association with virotype C, and high prevalence among ST131 isolates that produce CTX-M-15.
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Escherichia coli/enzimología , Escherichia coli/genética , beta-Lactamasas/genética , Adhesinas de Escherichia coli/genética , Tipificación de Bacteriófagos , Girasa de ADN/genética , Topoisomerasa de ADN IV/genética , Farmacorresistencia Bacteriana/genética , Escherichia coli/efectos de los fármacos , Infecciones por Escherichia coli/microbiología , Proteínas Fimbrias/genética , Humanos , Pruebas de Sensibilidad Microbiana , Plásmidos/genéticaRESUMEN
A liver transplant patient was admitted with cholangitis, for which meropenem therapy was started. Initial cultures showed a carbapenem-susceptible (CS) Escherichia coli strain, but during admission, a carbapenem-resistant (CR) E. coli strain was isolated. Analysis of the outer membrane protein profiles showed that both CS and CR E. coli lacked the porins OmpF and OmpC. Furthermore, PCR and sequence analysis revealed that both CS and CR E. coli possessed bla(CTX-M-15) and bla(OXA-1). The CR E. coli strain additionally harbored bla(CMY-2) and demonstrated a >15-fold increase in ß-lactamase activity against nitrocefin, but no hydrolysis of meropenem was detected. However, nitrocefin hydrolysis appeared strongly inhibited by meropenem. Furthermore, the CMY-2 enzyme demonstrated lower electrophoretic mobility after its incubation either in vitro or in vivo with meropenem, indicative of its covalent modification with meropenem. The presence of the acyl-enzyme complex was confirmed by mass spectrometry. By transformation of the CMY-2-encoding plasmid into various E. coli strains, it was established that both porin deficiency and high-level expression of the enzyme were needed to confer meropenem resistance. In conclusion, carbapenem resistance emerged by a combination of elevated ß-lactamase production and lack of porin expression. Due to the reduced outer membrane permeability, only small amounts of meropenem can enter the periplasm, where they are trapped but not degraded by the large amount of the ß-lactamase. This study, therefore, provides evidence that the mechanism of "trapping" by CMY-2 ß-lactamase plays a role in carbapenem resistance.
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Proteínas de la Membrana Bacteriana Externa/metabolismo , Permeabilidad de la Membrana Celular , Escherichia coli/efectos de los fármacos , Plásmidos/metabolismo , Tienamicinas/uso terapéutico , beta-Lactamasas/metabolismo , Antibacterianos/farmacología , Antibacterianos/uso terapéutico , Proteínas de la Membrana Bacteriana Externa/genética , Cefalosporinas/farmacología , Farmacorresistencia Bacteriana Múltiple , Activación Enzimática , Escherichia coli/enzimología , Escherichia coli/genética , Infecciones por Escherichia coli/tratamiento farmacológico , Proteínas de Escherichia coli/genética , Proteínas de Escherichia coli/metabolismo , Femenino , Humanos , Hidrólisis , Meropenem , Pruebas de Sensibilidad Microbiana , Periplasma/efectos de los fármacos , Plásmidos/genética , Unión Proteica , Tienamicinas/farmacología , Adulto Joven , beta-Lactamasas/genéticaRESUMEN
INTRODUCTION: Although diagnostic errors have gained renewed focus within the patient safety domain, measuring them remains a challenge. They are often measured using methods that lack information on decision-making processes given by involved physicians (eg, record reviews). The current study analyses serious adverse event (SAE) reports from Dutch hospitals to identify common contributing factors of diagnostic errors in hospital medicine. These reports are the results of thorough investigations by highly trained, independent hospital committees into the causes of SAEs. The reports include information from involved healthcare professionals and patients or family obtained through interviews. METHODS: All 71 Dutch hospitals were invited to participate in this study. Participating hospitals were asked to send four diagnostic SAE reports of their hospital. Researchers applied the Safer Dx Instrument, a Generic Analysis Framework, the Diagnostic Error Evaluation and Research (DEER) taxonomy and the Eindhoven Classification Model (ECM) to analyse reports. RESULTS: Thirty-one hospitals submitted 109 eligible reports. Diagnostic errors most often occurred in the diagnostic testing, assessment and follow-up phases according to the DEER taxonomy. The ECM showed human errors as the most common contributing factor, especially relating to communication of results, task planning and execution, and knowledge. Combining the most common DEER subcategories and the most common ECM classes showed that clinical reasoning errors resulted from failures in knowledge, and task planning and execution. Follow-up errors and errors with communication of test results resulted from failures in coordination and monitoring, often accompanied by usability issues in electronic health record design and missing protocols. DISCUSSION: Diagnostic errors occurred in every hospital type, in different specialties and with different care teams. While clinical reasoning errors remain a common problem, often caused by knowledge and skill gaps, other frequent errors in communication of test results and follow-up require different improvement measures (eg, improving technological systems).
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Background: In the previously reported SAPS trial (https://clinicaltrials.gov/ct2/show/NCT01139489), procalcitonin-guidance safely reduced the duration of antibiotic treatment in critically ill patients. We assessed the impact of shorter antibiotic treatment on antimicrobial resistance development in SAPS patients. Materials and methods: Cultures were assessed for the presence of multi-drug resistant (MDR) or highly resistant organisms (HRMO) and compared between PCT-guided and control patients. Baseline isolates from 30 days before to 5 days after randomization were compared with those from 5 to 30 days post-randomization. The primary endpoint was the incidence of new MDR/HRMO positive patients. Results: In total, 8,113 cultures with 96,515 antibiotic test results were evaluated for 439 and 482 patients randomized to the PCT and control groups, respectively. Disease severity at admission was similar for both groups. Median (IQR) durations of the first course of antibiotics were 6 days (4-10) and 7 days (5-11), respectively (p = 0.0001). Antibiotic-free days were 7 days (IQR 0-14) and 6 days (0-13; p = 0.05). Of all isolates assessed, 13% were MDR/HRMO positive and at baseline 186 (20%) patients were MDR/HMRO-positive. The incidence of new MDR/HRMO was 39 (8.9%) and 45 (9.3%) in PCT and control patients, respectively (p = 0.82). The time courses for MDR/HRMO development were also similar for both groups (p = 0.33). Conclusions: In the 921 randomized patients studied, the small but statistically significant reduction in antibiotic treatment in the PCT-group did not translate into a detectable change in antimicrobial resistance. Studies with larger differences in antibiotic treatment duration, larger study populations or populations with higher MDR/HRMO incidences might detect such differences.
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A study was designed to assess the importance of sequence types among extended-spectrum ß-lactamase (ESBL)-producing Escherichia coli isolates causing bacteremia over an 11-year period (2000 to 2010) in a centralized Canadian region. A total of 197 patients with incident infections were identified; the majority presented with community-onset urosepsis, with a significant increase in the prevalence of ESBL-producing E. coli during the later part of the study. The majority of E. coli isolates produced either CTX-M-15 or CTX-M-14. We identified 7 different major sequence types among 91% of isolates (i.e., the ST10 clonal complex, ST38, ST131, ST315, ST393, ST405, and ST648) and provided insight into their clinical and molecular characteristics. ST38 was the most antimicrobial-susceptible sequence type and predominated during 2000 to 2004 but disappeared after 2008. ST131 was the most antimicrobial-resistant sequence type, and the influx of a single pulsotype of this sequence type was responsible for the significant increase of ESBL-producing E. coli strains since 2007. During 2010, 49/63 (78%) of the ESBL-producing E. coli isolates belonged to ST131, and this sequence type had established itself as a major drug-resistant pathogen in Calgary, Alberta, Canada, posing an important new public health threat within our region. We urgently need well-designed epidemiological and molecular studies to understand the dynamics of transmission, risk factors, and reservoirs for E. coli ST131. This will provide insight into the emergence and spread of this multiresistant sequence type.
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Bacteriemia/epidemiología , Bacteriemia/microbiología , Infecciones por Escherichia coli/epidemiología , Infecciones por Escherichia coli/microbiología , Escherichia coli/clasificación , Escherichia coli/enzimología , beta-Lactamasas/metabolismo , Anciano , Anciano de 80 o más Años , Alberta , Técnicas de Tipificación Bacteriana , Canadá/epidemiología , Análisis por Conglomerados , Escherichia coli/genética , Escherichia coli/aislamiento & purificación , Femenino , Genotipo , Humanos , Masculino , Persona de Mediana Edad , Epidemiología Molecular , Tipificación de Secuencias Multilocus , beta-Lactamasas/genéticaRESUMEN
From international tourists to war-displaced refugees, more people are on the move than ever before. This provides the opportunity for a variety of antimicrobial-resistant bacteria to be carried from one geographic location to another. The Enterobacteriaceae are among the most important causes of serious hospital-acquired and community-onset bacterial infections in humans, and resistance to antimicrobial agents in these bacteria has become an increasingly relevant problem. International travel and tourism are important modes for the acquisition and spread of antimicrobial-resistant Enterobacteriaceae, especially CTX-M-producing Escherichia coli. Infections with KPC-, VIM-, OXA-48- and NDM-producing Enterobacteriaceae in developed countries have been associated with visiting and being hospitalized in endemic areas such as the USA, Greece and Israel for KPCs, Greece for VIMs, Turkey for OXA-48, and the Indian subcontinent for NDMs. To combat the spread of antimicrobial-resistant Enterobacteriaceae, the French Healthcare Safety Advisory Committee recently issued national recommendations for screening and contact isolation precautions for patients transferred from, or hospitalized outside, France. For effective public and patient health interventions, it is important to understand the role of international travel in the spread of antimicrobial-resistant Enterobacteriaceae. We urgently need well-designed studies to evaluate the transmission potential and risks for colonization and infections due to multiresistant Enterobacteriaceae in travellers who have recently visited or have been hospitalized in endemic areas. The emergence of CTX-M-, KPC- and NDM-producing bacteria is a good example of the role that globalization plays in the rapid dissemination of new antibiotic resistance mechanisms.
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Antibacterianos/farmacología , Transmisión de Enfermedad Infecciosa/estadística & datos numéricos , Farmacorresistencia Bacteriana Múltiple , Infecciones por Enterobacteriaceae/epidemiología , Infecciones por Enterobacteriaceae/transmisión , Enterobacteriaceae/efectos de los fármacos , Viaje , Países Desarrollados , Países en Desarrollo , Transmisión de Enfermedad Infecciosa/prevención & control , Enterobacteriaceae/enzimología , Enterobacteriaceae/aislamiento & purificación , Infecciones por Enterobacteriaceae/prevención & control , Salud Global , Humanos , beta-Lactamasas/metabolismoRESUMEN
OBJECTIVE: To study whether replacement of nosocomial ampicillin-resistant Enterococcus faecium (ARE) clones by vancomycin-resistant E. faecium (VRE), belonging to the same genetic lineages, increases mortality in patients with E. faecium bacteremia, and to evaluate whether any such increase is mediated by a delay in appropriate antibiotic therapy. DESIGN: Retrospective, matched-cohort study. SETTING: The study included 20 Dutch and Danish hospitals from 2009 to 2014. PATIENTS: Within the study period, 63 patients with VRE bacteremia (36 Dutch and 27 Danish) were identified and subsequently matched to 234 patients with ARE bacteremia (130 Dutch and 104 Danish) for hospital, ward, length of hospital stay prior to bacteremia, and age. For all patients, 30-day mortality after bacteremia onset was assessed. METHODS: The risk ratio (RR) reflecting the impact of vancomycin resistance on 30-day mortality was estimated using Cox regression with further analytic control for confounding factors. RESULTS: The 30-day mortality rates were 27% and 38% for ARE in the Netherlands and Denmark, respectively, and the 30-day mortality rates were 33% and 48% for VRE in these respective countries. The adjusted RR for 30-day mortality for VRE was 1.54 (95% confidence interval, 1.06-2.25). Although appropriate antibiotic therapy was initiated later for VRE than for ARE bacteremia, further analysis did not reveal mediation of the increased mortality risk. CONCLUSIONS: Compared to ARE bacteremia, VRE bacteremia was associated with higher 30-day mortality. One explanation for this association would be increased virulence of VRE, although both phenotypes belong to the same well-characterized core genomic lineage. Alternatively, it may be the result of unmeasured confounding.
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Bacteriemia , Enterococcus faecium , Infecciones por Bacterias Grampositivas , Ampicilina , Antibacterianos/farmacología , Antibacterianos/uso terapéutico , Bacteriemia/tratamiento farmacológico , Bacteriemia/epidemiología , Estudios de Cohortes , Dinamarca/epidemiología , Infecciones por Bacterias Grampositivas/tratamiento farmacológico , Infecciones por Bacterias Grampositivas/epidemiología , Humanos , Países Bajos/epidemiología , Estudios Retrospectivos , Vancomicina , Resistencia a la VancomicinaRESUMEN
BACKGROUND: Adults hospitalised to a non-intensive care unit (ICU) ward with moderately severe community-acquired pneumonia are frequently treated with broad-spectrum antibiotics, despite Dutch guidelines recommending narrow-spectrum antibiotics. Therefore, we investigated whether an antibiotic stewardship intervention would reduce the use of broad-spectrum antibiotics in patients with moderately severe community-acquired pneumonia without compromising their safety. METHODS: In this cross-sectional, stepped-wedge, cluster-randomised, non-inferiority trial (CAP-PACT) done in 12 hospitals in the Netherlands, we enrolled immunocompetent adults (≥18 years) who were admitted to a non-ICU ward and had a working diagnosis of moderately severe community-acquired pneumonia. All participating hospitals started in a control period and every 3 months a block of two hospitals transitioned from the control to the intervention period, with all hospitals eventually ending in the intervention period. The unit of randomisation was the hospital (cluster), and electronic randomisation (by an independent data manager) decided the sequence (the time of intervention) by which hospitals would cross over from the control period to the intervention period. Blinding was not possible. The antimicrobial stewardship intervention was a bundle targeting health-care providers and comprised education, engaging opinion leaders, and prospective audit and feedback of antibiotic use. The co-primary outcomes were broad-spectrum days of therapy per patient, tested by superiority, and 90-day all-cause mortality, tested by non-inferiority with a non-inferiority margin of 3%, and were analysed in the intention-to-treat population, comprising all patients who were enrolled in the control and intervention periods. This trial was prospectively registered at ClinicalTrials.gov, NCT02604628. FINDINGS: Between Nov 1, 2015, and Nov 1, 2017, 5683 patients were assessed for eligibility, of whom 4084 (2235 in the control period and 1849 in the intervention period) were included in the intention-to-treat analysis. The adjusted mean broad-spectrum days of therapy per patient were reduced from 6·5 days in the control period to 4·8 days in the intervention period, yielding an absolute reduction of -1·7 days (95% CI -2·4 to -1·1) and a relative reduction of 26·6% (95% CI 18·0-35·3). Crude 90-day mortality was 10·9% (242 of 2228 died) in the control period and 10·8% (199 of 1841) in the intervention period, yielding an adjusted absolute risk difference of 0·4% (90% CI -2·7 to 2·4), indicating non-inferiority. INTERPRETATION: In patients hospitalised with moderately severe community-acquired pneumonia, a multifaceted antibiotic stewardship intervention might safely reduce broad-spectrum antibiotic use. FUNDING: None.
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Programas de Optimización del Uso de los Antimicrobianos , Infecciones Comunitarias Adquiridas , Neumonía , Adulto , Antibacterianos/uso terapéutico , Infecciones Comunitarias Adquiridas/tratamiento farmacológico , Estudios Transversales , Humanos , Neumonía/tratamiento farmacológicoRESUMEN
We investigated the clinical and molecular characteristics of bacteremia caused by extended-spectrum-ß-lactamase (ESBL)-producing Escherichia coli over a 2-year period (2008 to 2009) in the Rotterdam region (including 1 teaching hospital and 2 community hospitals) of Netherlands. The majority of patients presented with community onset urinary and intra-abdominal infections, with an increase in prevalence during 2009. The majority of E. coli isolates produced CTX-M-15, and 4 sequence types (ST38, ST131, ST405, and ST648) predominated. There were significant differences in clinical and molecular characteristics between the 2 community hospitals.
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Bacteriemia/microbiología , Infecciones por Escherichia coli/microbiología , Escherichia coli/enzimología , Escherichia coli/patogenicidad , beta-Lactamasas/metabolismo , Adulto , Anciano , Bacteriemia/epidemiología , Infecciones por Escherichia coli/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Países Bajos , beta-Lactamasas/genéticaRESUMEN
BACKGROUND: The laboratory detection of Pseudomonas aeruginosa that produce metallo-ß-lactamases (MBLs) is not well defined in regions with a low prevalence of these enzymes. We report a study that developed ethylenediaminetetraacetic acid (EDTA) disk screen tests using doripenem, imipenem and meropenem and investigated the prevalence of these enzymes among clinical isolates of imipenem-resistant P. aeruginosa in Rotterdam during 2008-2009. METHODS: Using strains with well-characterized ß-lactamases and the Clinical and Laboratory Standards Institute (CLSI) disk methodology similar to extended-spectrum ß-lactamase (ESBL) detection, inhibition zone diameters were determined in tests with doripenem, imipenem, and meropenem, alone and in combination with 370 µg of EDTA. These tests were compared with the MBL E-test. A positive test was a ≥5 mm increase in zone diameter in the presence of EDTA. RESULTS: The imipenem EDTA disk screen test showed a sensitivity of 100% and a specificity of 90% in 96 recent clinical isolates. Imipenem in combination with doripenem performed better than imipenem alone, meropenem, and the MBL E-test (sensitivity of 100%; specificity of 95%). The majority of clinical isolates were isolated from patient respiratory specimens. Of the 96 imipenem-resistant P. aeruginosa isolated, 35 (36%) were positive for bla(VIM) genes. CONCLUSIONS: The EDTA imipenem/doripenem disk test showed accurate and reproducible results with excellent sensitivity and specificity. It is simple to perform and interpret and can be easily introduced into the workflow of a clinical laboratory to screen for MBLs in imipenem-resistant P. aeruginosa. Due to its high specificity the test is also suitable for regions with a low prevalence of these enzymes.
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Pruebas Antimicrobianas de Difusión por Disco/métodos , Infecciones por Pseudomonas/microbiología , Pseudomonas aeruginosa/enzimología , beta-Lactamasas/metabolismo , Antibacterianos/farmacología , Carbapenémicos/farmacología , Pruebas Antimicrobianas de Difusión por Disco/normas , Doripenem , Ácido Edético , Humanos , Imipenem/farmacología , Laboratorios , Meropenem , Pruebas de Sensibilidad Microbiana , Países Bajos , Infecciones por Pseudomonas/diagnóstico , Pseudomonas aeruginosa/clasificación , Pseudomonas aeruginosa/efectos de los fármacos , Pseudomonas aeruginosa/aislamiento & purificación , Reproducibilidad de los Resultados , Tienamicinas/farmacología , beta-Lactamasas/aislamiento & purificaciónRESUMEN
OBJECTIVES: Dutch guidelines recommend contact precautions in patients with multidrug resistant microorganisms cultured during the previous 12 months. To evaluate this policy, duration of carriage of multidrug resistant Enterobacterales was assessed among discharged hospital patients and patients attending their general practitioner (GP). Additionally, we assessed factors associated with clearance. METHODS: From January 2013 until May 2016, rectal or faecal samples accompanied by questionnaires on patient characteristics were obtained at time of study inclusion and 3, 6 and 12 months later, in 72 patients with multidrug resistant Enterobacterales. Clearance was defined as one or more negative cultures without a subsequent positive culture at 12 months after study inclusion. The percentage of clearance, intermittent carriage and persistence was determined and associated factors were assessed by logistic regression analysis. RESULTS: Clearance was found in 31 patients (43.1% [95%CI: 32.3-54.6]) of which 23 patients had two or more subsequent negative cultures. Twelve patients were classified as intermittent carriers (16.7% [95%CI: 9.8-26.9]) and 29 patients (40.3% [95% CI: 29.7-51.8]) as persistent carriers. Of the intermittent carriers, the majority (n=9) had two negative cultures during the study period. There was no difference in clearance between discharged hospitalized patients and GP patients. The only factor associated with clearance at 12 months in both univariable and multivariable analyses was not traveling to a foreign country (OR=3.5 [95%CI: 1.0-12.4]). CONCLUSION: Active screening for clearance of multidrug resistant Enterobacterales in patients within the health care setting is probably not beneficial due to high levels of intermittent and persistent carriage.
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Isolating a methicillin-resistant Staphylococcus aureus (MRSA) from a client receiving home care can be a reason for source and contact investigation in the home setting. However, the management of MRSA in a home care setting differs from one during a hospital admission. We describe a case of a patient with MRSA in a home care situation where both the microbiologist from the regional hospital and the communicable disease control physician from the municipal health services were involved. This case illustrates the different perspectives and points of view from both specialties, and the multidisciplinary approach that led to a strategic plan. In this article we discuss a strategy for conducting a contact investigation in public health.
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Trazado de Contacto/métodos , Infección Hospitalaria/prevención & control , Servicios de Atención de Salud a Domicilio , Staphylococcus aureus Resistente a Meticilina , Infecciones Estafilocócicas/prevención & control , Manejo de la Enfermedad , Humanos , Resistencia a la Meticilina , Staphylococcus aureusRESUMEN
OBJECTIVES: Since 1999, HIV testing is routinely offered to all attendees of the sexually transmitted infections (STI) outpatient clinic in Amsterdam, the Netherlands. This study evaluates whether this more active HIV-testing policy increased uptake of HIV testing and awareness of an HIV-positive serostatus among heterosexual attendees. METHODS: In addition to routine data collected at each STI consultation, data from half-yearly HIV surveys were used from 1994 to 2004. During each survey period, 1000 consecutive attendees are enrolled voluntary and anonymously for HIV testing and are interviewed on previous HIV testing and outcome. Trends in and predictors for uptake of HIV testing as offered during routine STI consultation were analysed by logistic regression. Trends in awareness of an HIV-positive serostatus as obtained from the anonymous HIV surveys were likewise analysed. RESULTS: The percentage of heterosexual attendees opting for an HIV test during consultation increased from 13% in 1996 to 56% in 2004. However, the proportion of individuals aware of their HIV infection did not change over time and only a minority (19%) of the 108 attendees found HIV-positive in the anonymous surveys were aware of their HIV infection. Persons being or visiting a commercial sex worker, having a non-Dutch ethnicity, lacking health insurance and having an STI diagnosed were less likely to opt for an HIV test. CONCLUSIONS: Although heterosexual attendees increased their uptake of HIV testing during STI consultation over time, uptake of testing by attendees at risk for HIV infection, such as those infected with an STI, remained low. As a result, the percentage of persons aware of their HIV infection remained low, posing a risk for their individual health and for ongoing HIV transmission. Current testing strategies, therefore, misses the group that most needs testing. Based on these results, 'opt-out' HIV testing is now the standard procedure at the Amsterdam STI clinic.
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Concienciación , Infecciones por VIH/diagnóstico , Heterosexualidad/estadística & datos numéricos , Enfermedades de Transmisión Sexual/diagnóstico , Enfermedades de Transmisión Sexual/epidemiología , Serodiagnóstico del SIDA/estadística & datos numéricos , Adulto , Factores de Edad , Femenino , Humanos , Masculino , Países Bajos , Aceptación de la Atención de Salud/etnología , Aceptación de la Atención de Salud/estadística & datos numéricos , Asunción de Riesgos , Factores SexualesRESUMEN
BACKGROUND: Recently, outbreaks of anorectal lymphogranuloma venereum (LGV) have occurred among men who have sex with men (MSM). This study identifies risk factors and clinical predictors of LGV to determine the implications for clinical practice. METHODS: The Chlamydia trachomatis serovars for all MSM who had anorectal chlamydia diagnosed at a sexually transmitted infection clinic in Amsterdam, The Netherlands, in 2002 and 2003 were retrospectively typed; 87 persons were infected with C. trachomatis serovar L2b and received a diagnosis of LGV. MSM infected with C. trachomatis serovars A-K and who thus had non-LGV anorectal chlamydia (n = 377) and MSM who reported having receptive anorectal intercourse but who did not have anorectal chlamydia (n = 2677) served as 2 separate control groups. Risk factors and clinical predictors were analyzed by multivariate logistic regression. Receiver operating characteristic curves were used to determine clinical relevance. RESULTS: HIV seropositivity was the strongest risk factor for LGV (odds ratio for patients with LGV vs. those with non-LGV chlamydia, 5.7 [95% confidence interval, 2.6-12.8]; odds ratio for patients with LGV vs. control subjects without chlamydia, 9.3 [95% confidence interval, 4.4-20.0]). Proctoscopic findings and elevated white blood cell counts in anorectal smear specimens were the only clinically relevant predictors for LGV infection (area under the curve of the receiver operating characteristic curve, > 0.71). Use of these 2 parameters and HIV infection status provided the highest diagnostic accuracy (for MSM with anorectal chlamydia, the area under the curve was > 0.82; sensitivity and specificity were 89% and 50%, respectively). CONCLUSIONS: LGV testing is recommended for MSM with anorectal chlamydia. If routine LGV serovar typing is unavailable, we propose administration of syndromic LGV treatment for MSM with anorectal chlamydia and either proctitis detected by proctoscopic examination, > 10 white blood cells/high-power field detected on an anorectal smear specimen, or HIV seropositivity.
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Homosexualidad Masculina , Linfogranuloma Venéreo/diagnóstico , Enfermedades del Recto/diagnóstico , Adulto , Estudios de Casos y Controles , Chlamydia trachomatis/clasificación , Chlamydia trachomatis/aislamiento & purificación , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Enfermedades del Recto/microbiología , Estudios Retrospectivos , Factores de RiesgoRESUMEN
OBJECTIVE: To compare guidelines on diabetes from different countries in order to examine whether differences in recommendations could be explained by use of different research evidence. RESEARCH DESIGN AND METHODS: We analyzed 15 clinical guidelines on type 2 diabetes from 13 countries using qualitative methods to compare the recommendations and bibliometric methods to measure the extent of overlap in citations used by different guidelines. A further qualitative analysis of recommendations and cited evidence for two specific issues in diabetes care explored the apparent discrepancy between recommendations and evidence. RESULTS: The recommendations made in the guidelines were in agreement about the general management of type 2 diabetes, with some important differences in treatment details. There was little overlap in evidence cited by the guidelines, with 18% (185/1,033) of citations shared with any other guideline, and only 10 studies (1%) appearing in six or more guidelines. The measurable overlap in evidence between guidelines increases if multiple publications from the same study and the use of reviews are taken into account. Research originating from the U.S. predominated (40% of citations); however, nearly all (11/12) guidelines were significantly more likely to cite evidence originating from their own countries. CONCLUSIONS: Despite the variation in cited evidence and preferential citation of evidence from a guideline's country of origin, we found a high degree of international consensus in recommendations made for the clinical care of type 2 diabetes. The influence of professional bodies such as the American Diabetes Association may be an important factor in explaining international consensus. Globalization of recommended management of diabetes is not a simple consequence of the globalization of research evidence.
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Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/terapia , Australia , Canadá , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/terapia , Europa (Continente) , Humanos , National Academies of Science, Engineering, and Medicine, U.S., Health and Medicine Division , Obesidad , Garantía de la Calidad de Atención de Salud , Sociedades Médicas , Estados UnidosRESUMEN
OBJECTIVE: To determine the number and duration of nosocomial outbreaks caused by highly resistant microorganisms (HRMO) posing a potential threat to public health, in order to undertake a risk assessment. DESIGN: Descriptive study. METHOD: Data on nosocomial outbreaks were collected from April 2012 to June 2014. The following characteristics were recorded at the start and end of each outbreak: type of microorganism, reason for reporting, phase of outbreak, number of patients colonised and infected, and infection prevention measures implemented. RESULTS: 47 medical institutions reported 87 outbreaks (mean: 3 outbreaks per month). 20 outbreaks were reported in 2012 (2.2/month), 39 in 2013 (3.3/month), and 28 in the first six months of 2014 (4.7/month). Outbreaks of vancomycin-resistant enterococci (n = 26), methicillin-resistant Staphylococcus aureus (MRSA; n = 23) and resistant or highly resistant Enterobacteriaceae (n = 17) were reported most frequently. 65 outbreaks (75%) were controlled within two months of reporting. CONCLUSION: Transparent reporting of HRMO outbreaks is important for correct public perceptions of the safety of hospitals and nursing homes in the Netherlands. Reports to the Hospital-acquired Infection and Antimicrobial Resistance Monitoring Group show that HRMO outbreaks are an almost daily occurrence in Dutch hospitals. However, most outbreaks are quickly controlled without posing a threat to public health.
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Infección Hospitalaria/epidemiología , Infección Hospitalaria/microbiología , Brotes de Enfermedades/estadística & datos numéricos , Farmacorresistencia Microbiana , Brotes de Enfermedades/prevención & control , Humanos , Países Bajos/epidemiología , Salud Pública , Medición de RiesgoRESUMEN
We investigated time trends in extended-spectrum cephalosporin-resistant Escherichia coli and Klebsiella pneumoniae isolates from different patient settings in The Netherlands from 2008-2012. E. coli and K. pneumoniae isolates from blood and urine samples of patients > = 18 years were selected from the Dutch Infectious Disease Surveillance System-Antimicrobial Resistance (ISIS-AR) database. We used multivariable Poisson regression to study the rate per year of blood stream infections by susceptible and resistant isolates, and generalized estimating equation (GEE) log-binomial regression for trends in the proportion of extended-spectrum cephalosporin-resistant isolates. Susceptibility data of 197,513 E. coli and 38,244 K. pneumoniae isolates were included. The proportion of extended-spectrum cephalosporin-resistant E. coli and K. pneumoniae isolates from urine and blood samples increased in all patient settings, except for K. pneumoniae isolates from patients admitted to intensive care units. For K. pneumoniae, there was a different time trend between various patient groups (p<0.01), with a significantly higher increase in extended-spectrum cephalosporin-resistant isolates from patients attending a general practitioner than in isolates from hospitalized patients. For E. coli, the increasing time trends did not differ among different patient groups. This nationwide study shows a general increase in extended-spectrum cephalosporin-resistant E. coli and K. pneumoniae isolates. However, differences in trends between E. coli en K. pneumoniae underline the importance of E. coli as a community-pathogen and its subsequent influence on hospital resistance level, while for K. pneumoniae the level of resistance within the hospital seems less influenced by the resistance trends in the community.
Asunto(s)
Cefalosporinas/uso terapéutico , Farmacorresistencia Bacteriana Múltiple , Infecciones por Escherichia coli/epidemiología , Escherichia coli/aislamiento & purificación , Infecciones por Klebsiella/epidemiología , Klebsiella pneumoniae/aislamiento & purificación , Adulto , Anciano , Anciano de 80 o más Años , Farmacorresistencia Bacteriana Múltiple/genética , Escherichia coli/efectos de los fármacos , Escherichia coli/enzimología , Escherichia coli/genética , Infecciones por Escherichia coli/tratamiento farmacológico , Infecciones por Escherichia coli/microbiología , Infecciones por Escherichia coli/orina , Femenino , Humanos , Infecciones por Klebsiella/tratamiento farmacológico , Infecciones por Klebsiella/microbiología , Infecciones por Klebsiella/orina , Klebsiella pneumoniae/efectos de los fármacos , Klebsiella pneumoniae/enzimología , Klebsiella pneumoniae/genética , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Países Bajos/epidemiología , Adulto Joven , beta-Lactamasas/genética , beta-Lactamasas/metabolismoRESUMEN
OBJECTIVE: This review evaluates the effectiveness of physical activity interventions among older adults. METHODS: Computerized searches were performed to identify randomized controlled trials. Studies were included if: (1) the study population consisted of older adults (average sample population age of > or =50 years and minimum age of 40 years); (2) the intervention consisted of an exercise program or was aimed at promoting physical activity; and (3) reported on participation (i.e., adherence/compliance) or changes in level of physical activity (e.g., pre-post test measures and group comparisons). RESULTS: The 38 studies included 57 physical activity interventions. Three types of interventions were identified: home-based, group-based, and educational. In the short-term, both home-based interventions and group-based interventions achieved high rates of participation (means of 90% and 84%, respectively). Participation declined the longer the duration of the intervention. Participation in education interventions varied widely (range of 35% to 96%). Both group-based interventions and education interventions were effective in increasing physical activity levels in the short-term. Information on long-term effectiveness was either absent or showed no difference of physical activity level between the study groups. CONCLUSIONS: Home-based, group-based, and educational physical activity interventions can result in increased physical activity, but changes are small and short-lived. Participation rates of home-based and group-based interventions were comparable, and both seemed to be unrelated to type or frequency of physical activity. The beneficial effect of behavioral reinforcement strategies was not evident. Comparative studies evaluating the effectiveness of diverse interventions are needed to identify the interventions most likely to succeed in the initiation and maintenance of physical activity.