Diagnoses and prescription patterns among users of medications for obstructive airway diseases in Finland.

BACKGROUND: Asthma and chronic obstructive pulmonary disease (COPD) are common diseases mostly treated in primary care. However, the usage patterns of drugs for obstructive airway diseases (R03 drugs) at the national level are not known. OBJECTIVE: The aims of this study were to describe (1) for which diagnoses each class of R03 drugs were used, (2) the usage pattern of different drug classes for asthma and COPD, and (3) how often these medications were used without a diagnosis of asthma or COPD in Finland. METHODS: We sent questionnaires that included questions on physician-diagnosed asthma and COPD to a random sample of 2000 Finnish subjects who had been dispensed R03 medications in the previous year. Details of R03 medications dispensed were retrieved from national registries. RESULTS: Altogether, 803 subjects (40.6%) responded. Of these, 61.6% had asthma, 5.7% had both asthma and COPD, 5.1% had COPD, and 27.5% had neither asthma nor COPD. Among subjects with asthma or asthma and COPD, inhaled corticosteroids (ICS) were the most frequently dispensed class of drugs (93.7% and 97.8%, respectively). Even among subjects with COPD, ICS were dispensed as frequently (68.3%) as long-acting bronchodilators (70.7%). Antileukotrienes were dispensed mainly to asthmatic individuals only (18.4%) but far less frequently than ICS. The use of theophylline and roflumilast was rare. CONCLUSIONS: R03 medications are dispensed far more frequently for asthma than for COPD and often also for subjects without asthma or COPD. In line with guidelines, asthma is treated mainly with ICS, but there seems to be overuse of ICS for COPD.

Age at asthma diagnosis and onset of symptoms among adults with allergic and non-allergic asthma.

Background: Childhood-onset allergic asthma is the best-known phenotype of asthma. Adult-onset asthma, also an important entity, is instead often shown to be more non-allergic. There is still a lack of studies concerning the association of allergies and age at asthma onset from childhood to late adulthood. The aim of the study was to assess the age at onset of asthma symptoms and age at asthma diagnosis among adults with allergic and non-allergic asthma. Methods: Questionnaires were sent to 2000 randomly selected Finnish adults aged 18-80 years who were dispensed medication for obstructive airway diseases during the previous year. The corrected sample size was 1978 subjects after exclusion of non-analysable data. The response rate was 40.6%. Self-reported doctor-diagnosed asthma was considered allergic if a concomitant self-reported doctor-diagnosed pollen and/or animal allergy was reported with asthma symptoms upon allergen exposure. Results: Of the 496 participants with asthma, 42.7% were considered to have allergic asthma. The median ages at asthma diagnosis and onset of asthma symptoms were 31 (IQR 17-46) and 20 (9.25-40) years in participants with allergic asthma and 49 (37.75-58) and 40.5 (30-50) years in participants with non-allergic asthma (p < 0.001), respectively. Of the participants with asthma diagnosed at ≥30 years of age, 18% of allergic and 7% of non-allergic participants reported having had asthma symptoms under 20 years of age. Conclusions: Both the onset of symptoms and diagnosis occurred at a younger age among adults with allergic asthma than among those with non-allergic asthma. Only a minority of adults with non-allergic asthma had already had symptoms in younghood.

Adherence to treatment guidelines and good asthma control in Finland.

Background: Asthma program in Finland decreased asthma-related mortality and expenses of care on national level, but there is lack of data on adherence to treatment guidelines and disease control on individual level. We aimed to assess adherence to guidelines and disease control among Finnish adult asthmatics. Methods: Questionnaires were sent in Finland to 2000 randomly selected recipients aged 18-80 years, who had bought medication for obstructive airways disease during the previous 12 months. The questionnaire included questions on asthma medication, exacerbations, self-management and follow-up. Asthma symptom control was assessed by the Asthma Control Test (ACT). Results: A high proportion (82.4%) of the 541 responders with physician-diagnosed asthma reported regular use of asthma medication and 97.1% of them used inhaled corticosteroids. Almost all (97.0%) of the asthmatics were taught how to use their inhaler and 78.4% had an asthma self-management plan, but only 35.7% reported regular annual follow-up visits. According to symptoms, 60.0% had their asthma well-controlled (ACT score ≥20). On the other hand, 29.2% had a course of oral corticosteroid and 21.8% had an asthma-related unscheduled health care visit during the previous year, but only 2.6% reported a hospitalization. Asthma control was better in those not using regular asthma medication. Conclusions: The guidelines are well adopted in Finnish adult asthma care except for regular follow-up visits. Majority of patients had good symptom control and hospitalizations were rare. Better asthma control among those not using regular asthma medication implies they are not undertreated but have a mild disease.

Functional genomics in Campylobacter coli identified a novel streptomycin resistance gene located in a hypervariable genomic region.

Numerous aminoglycoside resistance genes have been reported in Campylobacter spp. often resembling those from Gram-positive bacterial species and located in transferable genetic elements with other resistance genes. We discovered a new streptomycin (STR) resistance gene in Campylobactercoli showing 27-34 % amino acid identity to aminoglycoside 6-nucleotidyl-transferases described previously in Campylobacter. STR resistance was verified by gene expression and insertional inactivation. This ant-like gene differs from the previously described aminoglycoside resistance genes in Campylobacter spp. in several aspects. It does not appear to originate from Gram-positive bacteria and is located in a region corresponding to a previously described hypervariable region 14 of C. jejuni with no other known resistance genes detected in close proximity. Finally, it does not belong to a multiple drug resistance plasmid or transposon. This novel ant-like gene appears widely spread among C. coli as it is found in strains originating both from Europe and the United States and from several, apparently unrelated, hosts and environmental sources. The closest homologue (60 % amino acid identity) was found in certain C. jejuni and C. coli strains in a similar genomic location, but an association with STR resistance was not detected. Based on the findings presented here, we hypothesize that Campylobacter ant-like gene A has originated from a common ancestral proto-resistance element in Campylobacter spp., possibly encoding a protein with a different function. In conclusion, whole genome sequencing allowed us to fill in a knowledge gap concerning STR resistance in C. coli by revealing a novel STR resistance gene possibly inherent to Campylobacter.

Effect of ciprofloxacin exposure on DNA repair mechanisms in Campylobacter jejuni.

Ciprofloxacin resistance is common both among animal and human Campylobacter jejuni isolates. Resistant isolates are shown to persist even without selection pressure. To obtain further insight on effects of ciprofloxacin exposure on C. jejuni we compared transcriptional responses of both C. jejuni wild-type strain 81-176 (ciprofloxacin MIC 0.125 mg l(-1)) and its intermediate ciprofloxacin-resistant variant P3 (Asp90→Asn in GyrA) in the absence and presence of ciprofloxacin. Further, we sequenced the genome of P3 and compared the sequence with that of wild-type 81-176. One hour of exposure to 8 mg l(-1) of ciprofloxacin did not decrease the viability of the parent strain 81-176. Transcriptional analysis revealed that ciprofloxacin exposure caused changes in the expression of genes involved in DNA replication and repair. While in the wild-type the exposure caused downregulation of several genes involved in the control of DNA replication and recombination, the genes controlling nucleotide excision repair and DNA modification were upregulated in both the wild-type and P3. In addition, we observed that ciprofloxacin exposure caused upregulation of genes responsible for damage recognition in base excision repair in P3. In contrast, without ciprofloxacin exposure, DNA repair mechanisms were substantially downregulated in P3. The genome sequence of P3 compared to that of the 81-176 parental strain had three non-synonymous substitutions and a deletion, revealing that the resistant variant had maintained genetic integrity. In conclusion, enhanced DNA repair mechanisms under ciprofloxacin exposure might explain maintenance of genomic integrity in ciprofloxacin-resistant variant P3.

Campylobacter coli isolates from Finnish farrowing farms using aminopenicillins: high prevalence of bla(OXA-61) and ß-lactamase production, but low MIC values.

Antimicrobial treatment of animals may select resistance in Campylobacter to antimicrobial agents belonging to several classes of compounds. We investigated the effect of widely used aminopenicillin therapy on the minimum inhibitory concentration (MIC) levels in porcine Campylobacter coli isolates and investigated the presence of a ß-lactamase gene and ß-lactamase production. Epidemiological cut-off values (ECOFFs) were applied to detect decreased susceptibility. Fifty-three isolates were obtained from aminopenicillin-treated (ampicillin or amoxicillin) sows and piglets during and up to 3 weeks post-treatment. All isolates had ampicillin MICs below the ECOFF (≤ 8 µg/mL). An additional 63 isolates were sampled before treatment or from other untreated sows and piglets. Of these isolates, four had ampicillin MICs above the ECOFF. All ciprofloxacin MICs were below the ECOFF (≤ 1 µg/mL), except for three isolates from untreated sows and four isolates after aminopenicillin therapy. One isolate originating from an untreated sow had an erythromycin MIC above the ECOFF (> 16 µg/mL). None of the isolates had MICs above the ECOFFs for two or three studied antimicrobials simultaneously. Of the 116 C. coli isolates, 90 (77.6%) isolates carried the bla(OXA-61) ß-lactamase gene, and 63 (70.0%) of those produced ß-lactamase. The isolates producing ß-lactamase had higher ampicillin MICs than those without the bla(OXA-61) gene and production of ß-lactamase. Proportion of the bla(OXA-61)-positive C. coli isolates was similar among untreated animals or during and after the treatment. In conclusion, C. coli isolates did not acquire high ampicillin MICs even though aminopenicillins were administered at therapeutic levels for several days. The bla(OXA-61) gene and production of ß-lactamase increased ampicillin MICs in C. coli, but the values remained mainly under the ECOFF. We also demonstrated that aminopenicillin therapy did not select simultaneously resistance to the major antimicrobials used in human therapy against campylobacteriosis (i.e., erythromycin and ciprofloxacin).

Tracing Campylobacter jejuni strains along the poultry meat production chain from farm to retail by pulsed-field gel electrophoresis, and the antimicrobial resistance of isolates.

In this study Campylobacter jejuni isolates were recovered from birds, carcasses and carcass portions from two broiler chicken flocks and from equipment used for carcass and meat processing along the production chain from farms to retail stores. Isolates were subjected to pulsed-field gel electrophoresis (PFGE) using SmaI and KpnI restriction enzymes and their antimicrobial susceptibilities were determined. C. jejuni was recovered from product and equipment used with both flocks at each point in the production chain. The prevalence of C. jejuni in poultry products at retail stores was 58.97% (flock 1) and 69.23% (flock 2). SmaI divided 122 C. jejuni strains from flock 1 and 106 from flock 2 into 17 and 13 PFGE types, respectively. PFGE types H and F were present at all steps along the chain, from farms to retail products. Similarly, for both flocks PFGE type D was detected in crates, slaughterhouse and retail stores. Moreover, the PFGE types were highly diverse at the processing and retail steps. Most PFGE types were resistant to ciprofloxacin (95.45%) and tetracycline (81.82%); and multidrug resistant PFGE types were found in the final products. Our study showed that there were several points of cross-contamination of product along the chain, and a high diversity of PFGE types with antimicrobial resistance to ciprofloxacin and tetracycline in the retail products.

Importance of RNA stabilization: evaluation of ansB, ggt, and rpoA transcripts in microaerophilic Campylobacter jejuni 81-176.

A subset of food-borne Campylobacter jejuni strains utilizes amino acids asparagine and glutamine as carbon sources that may enhance the ability of this microaerophilic pathogen to colonize specific tissues. In this study, we analyzed the transcript sizes of the ansB and ggt genes encoding the periplasmic asparaginase and γ-glutamyltranspeptidase in C. jejuni 81-176, respectively, and compared the expression level of mRNAs at different time points during the growth in vitro. In addition, we included the housekeeping rpoA gene, encoding the α-subunit of DNA-directed RNA polymerase, to monitor sample processing as it has been described as a stable reference gene in gene expression studies in C. jejuni. Our results revealed that both the ansB and ggt genes were expressed in the end of the logarithmic growth phase and their corresponding monocistronic mRNAs were not affected by sample processing steps. In contrast, the mRNAs of the polycistronic operon containing rpoA gene were highly induced at earlier stage of the logarithmic growth and were clearly differentially responding to external factors during cell harvesting step.

Longitudinal on-farm study of the development of antimicrobial resistance in Campylobacter coli from pigs before and after danofloxacin and tylosin treatments.

Effects of danofloxacin or consecutive fluoroquinolone and macrolide treatments on resistance development in Campylobacter have remained uncharacterised. Therefore we analysed the development of resistance in porcine Campylobacter coli before and after danofloxacin and tylosin treatments at a farrowing farm. Danofloxacin-treated (n=12, group A) and control pigs (n=15, group B) were subsequently treated with tylosin and sampled longitudinally. C. coli were isolated and susceptibilities to ciprofloxacin and erythromycin were assessed, isolates were genotyped with PFGE and resistance-related mutations were identified. Isolates from the danofloxacin-treated pigs had more frequently non-wild type MICs (above the epidemiological cut-off value (ECOFF)) for ciprofloxacin (P<0.001) and erythromycin (P<0.05) than those isolated before danofloxacin or those from the controls. Subsequent tylosin treatment increased proportion of isolates with non-wild type MICs for erythromycin in both groups A and B (P<0.01) and, interestingly, proportion of isolates with non-wild type MICs for ciprofloxacin in group B (P<0.001) with high MICs (128 µg/ml). PFGE analysis revealed treatments selecting predominant genotypes with variable resistance patterns and decreasing initial diversity of genotypes. The most common genotype had mainly high MICs for ciprofloxacin among danofloxacin-treated pigs but wild type MICs (below the ECOFF) among the controls housed in the same pens. This suggests that the non-wild type isolate was rarely transmitted or outcompeting wild type genotype in the control pigs without selection pressure. Isolates exhibiting non-wild type MICs for ciprofloxacin harboured the C257T (Thr-86-Ile) mutation in the gyrA gene. In conclusion, a high dose of danofloxacin used at the farm did not prevent emergence of isolates with high MICs for ciprofloxacin. After subsequent tylosin treatment isolates had even higher MICs for ciprofloxacin and erythromycin than before the treatment. Therefore, controlled use of antimicrobials in food animal production is essential.

Mutations in the rpsL gene are involved in streptomycin resistance in Campylobacter coli.

To characterize the mechanisms of streptomycin (STR) resistance in Campylobacter coli, we chose 17 isolates that were resistant to STR, erythromycin (ERY), or both, and the putative STR resistance target genes rpsL, rrs, and gidB were analyzed for mutations. The presence of the aadE gene encoding aminoglycoside 6-adenylyltransferase was also evaluated. To reveal putative connection between ERY and STR resistance mechanisms, 13 C. coli isolates initially susceptible to STR and ERY were exposed to STR, and resistant variants were characterized. We also assessed the development of ERY resistance with a similar method. Finally, the effect of the putative CmeABC efflux pump inhibitor phenyl-arginine-beta-naphthylamine on STR resistance was tested. Our studies showed an association between mutations in the rpsL gene and STR resistance in C. coli. Further, mutations obtained in vitro were more diverse than those occurring in vivo. However, we observed no resistance associated mutations in the other genes studied, and selection with STR did not result in variants resistant to ERY and vice versa. None of the isolates harbored the aadE gene, and no differences in STR minimum inhibitory concentration levels were detected in the presence or absence of phenyl-arginine-beta-naphthylamine. In conclusion, we found that STR resistance was associated with mutations in the rpsL gene, but no obvious association between STR and ERY resistance mechanisms was found in C. coli.