Monitoring of tobramycin serum concentrations in selected critically ill patients receiving selective decontamination of the digestive tract: a retrospective evaluation.

INTRODUCTION: Selective decontamination of the digestive tract (SDD) is a strategy in mechanically ventilated patients to reduce mortality. Treatment consists of enterally administered non-absorbable antibiotics, i.e., tobramycin. However, most intensive care unit (ICU) patients with SDD appear to have detectable tobramycin serum concentrations. The Rijnstate Hospital implemented a protocol for therapeutic drug monitoring (TDM) of tobramycin in patients at risk. The aim of this study was to evaluate the necessity of TDM in these patients and to optimize the current protocol. METHODS: This retrospective observational study included ICU patients with SDD treatment for ≥ 7 days and renal failure. These patients were considered eligible for monitoring of tobramycin. Tobramycin serum concentrations, relevant laboratory parameters (i.e., renal function, lactate), and patient data were extracted from the National Intensive Care Evaluation database and the hospital electronic patient data system. RESULTS: In 23 subjects, a total of 43 tobramycin serum concentrations was determined. The median tobramycin serum concentration was 0.33 (IQR 0.17-0.49) mg/L of which 12 (27.9%) samples had concentrations < 0.2 mg/L, 30 (69.8%) had concentrations 0.2-1.0 mg/L and 1 (2.3%) had a toxic concentration > 1.0 mg/L. In 3 (7.0%) cases, an intervention was conducted based on the tobramycin serum concentration. CONCLUSION: The majority (83.7%) of samples had detectable tobramycin serum concentrations. Monitoring of tobramycin serum concentrations can be considered necessary in patients at risk. However, the current protocol should be optimized to intercept patients more precise.

Decontamination of the digestive tract and oropharynx in ICU patients.

BACKGROUND: Selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) are infection-prevention measures used in the treatment of some patients in intensive care, but reported effects on patient outcome are conflicting. METHODS: We evaluated the effectiveness of SDD and SOD in a crossover study using cluster randomization in 13 intensive care units (ICUs), all in The Netherlands. Patients with an expected duration of intubation of more than 48 hours or an expected ICU stay of more than 72 hours were eligible. In each ICU, three regimens (SDD, SOD, and standard care) were applied in random order over the course of 6 months. Mortality at day 28 was the primary end point. SDD consisted of 4 days of intravenous cefotaxime and topical application of tobramycin, colistin, and amphotericin B in the oropharynx and stomach. SOD consisted of oropharyngeal application only of the same antibiotics. Monthly point-prevalence studies were performed to analyze antibiotic resistance. RESULTS: A total of 5939 patients were enrolled in the study, with 1990 assigned to standard care, 1904 to SOD, and 2045 to SDD; crude mortality in the groups at day 28 was 27.5%, 26.6%, and 26.9%, respectively. In a random-effects logistic-regression model with age, sex, Acute Physiology and Chronic Health Evaluation (APACHE II) score, intubation status, and medical specialty used as covariates, odds ratios for death at day 28 in the SOD and SDD groups, as compared with the standard-care group, were 0.86 (95% confidence interval [CI], 0.74 to 0.99) and 0.83 (95% CI, 0.72 to 0.97), respectively. CONCLUSIONS: In an ICU population in which the mortality rate associated with standard care was 27.5% at day 28, the rate was reduced by an estimated 3.5 percentage points with SDD and by 2.9 percentage points with SOD. (Controlled Clinical Trials number, ISRCTN35176830.)

[A midwife involved in patients with puerperal fever in three different hospitals]. / Een verloskundige betrokken bij patiënten met kraamvrouwenkoorts in drie verschillende ziekenhuizen.

In three hospitals three women aged 34, 33 and 25 years respectively, developed fever following delivery; in two of them a beta-haemolytic streptococcus of Lancefield group A (GAS) was cultured. Between the time of transmission of the infective agent of the first and the third patients there was a period of ten days. Because the intervals between the emergence of cases were relatively long, the suspicion of a common vector, i.e. the midwife, was raised only after some time. The midwife who had been present at all three deliveries turned out to be negative for GAS carriership on three occasions. However, cultures taken from her son and partner were positive for GAS carriership. A number of typing systems were unable to distinguish the GAS-isolates from the first two patients and from the son. After the midwife and her family members had been treated, no new cases occurred. This case illustrates the importance of keeping midwives as well as the department of public health informed of a rise in the number of cases of puerperal fever, whether the cases involve more than one hospital or not, in order to prevent a potential epidemic. Only then can a common source be looked for and the epidemic contained.

[Invasive Lancefield group A streptococcal infections in the Netherlands]. / Invasieve infecties met streptokokken uit lancefield-groep A in Nederland.

After a steady decrease in morbidity and mortality resulting from severe group A streptococcal (GAS) infections, the 1980s witnessed a resurgence of invasive GAS disease. As a result a nationwide laboratory-based surveillance for invasive GAS infections was conducted at the National Institute of Public Health (RIVM) from 1994 to 2003. The estimated annual incidence ranged from 2.0 to 4.0 cases per 100,000 individuals per year. The case-fatality rate was 18% overall but varied substantially depending on the manifestation of the disease. GAS infections may be complicated by toxic shock-like syndrome (TSS) which is caused by bacterial exotoxins. Case fatality among TSS cases was 59%. The M-protein that extends from the cell membrane is used for sub-typing GAS in > 150 different M-types. Increased intrinsic virulence has been reported in Streptococcus pyogenes of certain M-types, notably M1 and M3. In the Netherlands these M-types have been independently associated with fatality. Over the last 50 years the genome of these M-types appears to have become enriched with phage-encoded virulence factors, possibly contributing to the altered epidemiology of invasive GAS disease. Despite this genetic plasticity, GAS have remained uniformly susceptible to penicillin. In-vitro studies have shown that the administration of immunoglobulin G can have a neutralising effect in cases ofTSS but clinical studies have failed to provide any statistical support for this.

Genotyping and preemptive isolation to control an outbreak of vancomycin-resistant Enterococcus faecium.

BACKGROUND: Control of vancomycin-resistant Enterococcus faecium (VRE) in European hospitals is hampered because of widespread asymptomatic carriage of VRE by healthy Europeans. In 2000, our hospital (The University Medical Center Utrecht, Utrecht, The Netherlands) was confronted with a large outbreak of VRE. INTERVENTION: On the basis of genotyping (by pulsed-field gel electrophoresis), epidemic and nonepidemic VRE strains were distinguished, and infection-control measures were exclusively targeted toward epidemic VRE. The outbreak was retrospectively divided into 3 periods of different infection-control measures. Compliance with use of alcohol-based hand rubs was enforced during all periods. Period I involved active surveillance, isolation of carriers, and cohorting (duration, 4 months); preemptive isolation of high-risk patients for VRE colonization was added in period II (7 months); and cohorting and preemptive isolation were abandoned in period III (18 months). METHODS: When the outbreak was identified, 27 patients in 6 wards were colonized; 93% were colonized with an epidemic VRE strain. Detection rates of nonepidemic VRE were 3.5%, 3.0%, and 2.9% among 683, 810, and 977 screened patients in periods I, II, and III, respectively, comparable to a prevalence of 2% (95% confidence interval [CI], 1%-3.5%) among 600 nonhospitalized persons. The relative risks of detecting epidemic VRE in periods II and III, compared with period I, were 0.67 (95% CI, 0.41-1.10) for period II and 0.02 (95% CI, 0.002-0.6) for period III. Infection-control measures were withheld for patients colonized with nonepidemic VRE (76 [54%] of 140 patients with a test result positive for VRE). Use of alcohol-based hand rubs increased by 31%-275% in outbreak wards. CONCLUSION: Genotyping-targeted infection control, isolation of VRE carriers, enhancement of hand-hygiene compliance, and preemptive isolation successfully controlled nosocomial spread of epidemic VRE infection.

Epidemiology of multiple Acinetobacter outbreaks in The Netherlands during the period 1999-2001.

An increase in the number of outbreaks of Acinetobacter infection was notified in The Netherlands during 1999-2001. The present study compared the outbreaks at the species and strain levels, and analysed the epidemiology and control measures at the different locations. For each institute, three representative isolates from three patients were identified to the species and strain levels by genotyping methods. A questionnaire investigated the impact of the outbreak, the control measures that were taken, and the possible effects of the measures. Seven outbreaks were associated with Acinetobacter baumannii (three outbreaks with a strain designated strain A, two outbreaks with a strain designated strain B, and one outbreak each with strains designated C and D). An additional outbreak was caused by genomic species 13TU, which is related closely to A. baumannii. Strains B and D were identified as European clones III and II, respectively. Except for two hospitals with outbreaks caused by strain A, there was no known epidemiological link between the participating hospitals. In all hospitals the outbreak occurred on one or several intensive care units, and spread to other departments was noted in two hospitals. The number of patients affected ranged from six to 66 over a period of 2-22 months. In most outbreaks, patients were the likely reservoir from which spread occurred. In all hospitals, a large panel of measures was required to bring the outbreak to an end. Extensive environmental sampling yielded numerous positive samples in most but not all hospitals.

Phosphorylation of pyruvate kinase type K is restricted to the dimeric form.

In the absence of glycolytic intermediate, fructose-1,6-bisphosphate, pyruvate kinase type K exists in the dimeric form and is readily phosphorylated, whereas in the same sample and the same conditions pyruvate kinase type M is present as a tetramer and is not phosphorylated. Addition of fructose-1,6-bisphosphate results in the association of dimeric K2 molecules to a tetrameric K4 enzyme as determined by gel filtration and cellulose acetate electrophoresis, with concomitant loss of the capacity of the K isozyme to become phosphorylated. Phosphorylated K2 dimers can also tetramerize, but with a low recovery of the radiolabel, suggesting a fructose-1,6-bisphosphate induced dephosphorylation or selective degradation. The dimeric K isozyme is enzymatically active; inactive K-type monomers can be detected by immunoblot analysis in the absence of fructose-1,6-bisphosphate, but no phosphorylated pyruvate kinase is present in this fraction. The formation of K4 tetramers can not be accomplished by the substrate phosphoenolpyruvate. Fructose-1,6-bisphosphate is an allosteric activator of pyruvate kinase type K and induces hyperbolic saturation curves for phosphoenolpyruvate. In contrast, in the absence of effectors, pyruvate kinase type M exhibits Michaelis-Menten kinetics, but sigmoidal curves can be induced by the amino acid phenylalanine. However, even in the presence of phenylalanine, the M-type maintained its tetrameric configuration and did not serve as a substrate in the phosphorylation reaction. These findings argue for the importance of subunit interaction in the regulation of phosphorylation of pyruvate kinase.

Vancomycin-resistant enterococci: consequences for therapy and infection control.

Vancomycin-resistant enterococci (VRE) have emerged as important nosocomial pathogens, initially in the USA, but now also in Europe, where hospital outbreaks are being reported with increasing frequency, although the incidence of VRE infections remains extremely low in most European countries. The recently demonstrated in-human transmission of vancomycin resistance from VRE to methicillin-resistant Staphylococcus aureus (MRSA) in two American patients underscores the potential danger of a coexisting reservoir of both pathogens. As MRSA is already endemic in many European hospital settings, prevention of endemicity with VRE seems relevant, but should be balanced against the costs associated with the implementation of effective strategies. The presence of a large community reservoir of VRE in Europe could hamper the feasibility of infection control strategies. Although the prevalence of colonisation amongst healthy subjects has apparently decreased after the ban on avoparcin use in the agricultural industry, a large proportion of admitted patients are still potential sources of VRE transmission. With no risk profile available to identify these carriers, effective screening, followed by barrier precautions for carriers, seems to be impossible. Recent studies, however, have suggested that hospital outbreaks are almost exclusively caused by specific genogroups of VRE that can be characterised phenotypically and genotypically (e.g., co-resistance to ampicillin and the presence of the variant esp gene). Based on our own experience, we propose that VRE infection control programmes should be restricted to patients colonised with these VRE strains. If such a strain is cultured from a clinical sample, surveillance amongst contact patients is recommended and barrier precautions should be implemented in the case of documented spread.

Long-term surveillance of invasive group A streptococcal disease in The Netherlands, 1994-2003.

A nationwide laboratory-based surveillance study of invasive group A streptococcal (GAS) infections was conducted in The Netherlands from May 1994 until December 2003 (average population during this period was 15 729 704). Microbiologically invasive isolates were obtained from 1504 patients, with most (70%) isolates cultured from blood. There was a clear seasonal pattern in invasive streptococcal infections, with an estimated annual incidence that peaked in 1996 (4.0 cases/100 000 individuals/year) and was at its lowest in 1999 (2.0 cases/100 000 individuals/year). Twenty-eight different M-types were identified, of which the most frequent were M1 (339/1504, 23%), M3 (187/1504, 12%), M89 (174/1504, 12%), M28 (164/1504, 11%), M12 (109/1504, 7%) and M6 (55/1504, 4%). There was a high degree of variation in the relative annual contributions of the predominant M-types, but variations in M1 and M3 combined correlated with overall changes in the annual incidence. The contribution of the patient group aged > or = 56 years to all cases of invasive GAS disease increased during the study period, whereas that of the group aged 0-20 years decreased. A peak in the incidence of invasive GAS disease among the patient group aged 30-34 years did not vary during the study period, indicating that the high incidence of invasive GAS disease in this age group was age-specific rather than cohort-related.

Predicting carriage with extended-spectrum beta-lactamase-producing bacteria at hospital admission: a cross-sectional study.

The prevalence of patients colonized with extended-spectrum beta-lactamase (ESBL)-producing bacteria increases, especially in long-term-care facilities (LTCFs). Identification of ESBL carriers at hospital admission is relevant for infection control measures and antibiotic therapy for nosocomial infections. We aimed to develop a prediction rule for ESBL carriage at hospital admission for patients admitted from home and LTCFs, and to quantify incidences of nosocomial infections caused by ESBL-producing bacteria. The ESBL-carrier status was determined of patients admitted from LTCFs and from home settings in four hospitals in the Netherlands using perianal swabs obtained within 48 hours of admission. Risk factors for ESBL carriage were assessed. Infections caused by ESBL-producing bacteria were identified retrospectively. Among 1351 patients, 111 (8.2%) were ESBL carriers at admission: 50/579 (8.6%) admitted from LTCFs and 61/772 (7.9%) from home settings (p 0.63). Previous ESBL carriage and previous hospital admission were risk factors for ESBL carriage in multivariable analysis. The area under the curve of the receiver operating characteristic curve of the model was 0.64 (95% CI 0.58-0.71). Presence of ≥1 risk factor (n = 803; 59%) had sensitivity of 72%. Incidences of nosocomial infections caused by ESBL-producing bacteria were 45.5/10,000 and 2.1/10,000 admission days for ESBL carriers and non-carriers, respectively (p <0.05). In conclusion, prevalence of ESBL carriage at hospital admission was 8.2%, and was comparable among patients admitted from LTCF and home. A clinically useful prediction rule for ESBL carriage at admission could not be developed. The absolute incidence of nosocomial infections by ESBL-producing bacteria was low, but higher among patients carrying ESBL-producing bacteria at the time of hospital admission.

Penicillin and clindamycin differentially inhibit the production of pyrogenic exotoxins A and B by group A streptococci.

Streptococcal pyrogenic exotoxins A (SPE-A) and B (SPE-B) have been implicated in the pathogenesis of serious group A streptococcal infections including streptococcal toxic shock-syndrome. Current antibiotics used for the treatment of these infections are penicillin and clindamycin. The effects of sub- and suprainhibitory concentrations of penicillin and clindamycin were evaluated in 14 isolates of Streptococcus pyogenes that were fully susceptible to both antibiotics. Clindamycin was superior to penicillin in reducing the production of SPE-A and SPE-B by invasive and non-invasive Dutch group A streptococcal isolates in vitro.

Outbreak of a susceptible strain of Acinetobacter species 13 (sensu Tjernberg and Ursing) in an adult neurosurgical intensive care unit.

Between December 1999 and June 2000, an outbreak caused by Acinetobacter emerged on the neurosurgical intensive care unit of our hospital. It was shown using automated ribotyping using Eco RI and pulsed-field gel electrophoresis that the outbreak was caused by spread of a single strain, which was identified by ribotyping and amplified ribosomal DNA restriction analysis as Acinetobacter DNA group 13TU (sensu Tjernberg and Ursing). The outbreak strain, which showed no antibiotic resistance, was identified in 23 patients, five of whom developed an infection. The organism was also isolated from various environmental sites. Cross-transmission among patients continued despite contact isolation of colonized patients and reinforcement of basic disinfection procedures. Eventually, after implementation of additional stringent measures such as cohorting of positive patients and daily disinfection of the floor, the outbreak was brought under control. This study demonstrates that apart from Acinetobacter baumanii, Acinetobacter 13TU strains, even when they are fully susceptible, may cause outbreaks that are difficult to control. Correct identification to the species level of Acinetobacter by genotypic methods is necessary to get insight in the importance of the different Acinetobacter genomic species in hospital epidemiology.

[A pseudo-epidemic of puerperal sepsis]. / Een pseudo-epidemie van kraamvrouwenkoorts.

Within a four-week period, five patients were admitted to the maternity ward of the Utrecht Children's Hospital diagnosed with puerperal sepsis due to group-A streptococcal infection. The clinical presentation was different for each patient. All patients recovered upon adequate antibiotic treatment. One of the children died, possibly due to sepsis and hypotension of his mother. As group-A streptococci can be extremely contagious and an epidemic was suspected, measures for additional hygiene were taken. Furthermore, all personnel at the maternity ward and the obstetric centre were tested. T-serotyping, M-genotyping, exotoxin A- and C-gene amplification and pulsed field gel electrophoresis were used to characterize the cultured group-A streptococci. Cross-contamination was not found. Therefore, this increase in puerperal sepsis was attributed to polyclonal expansion rather than an epidemic. All mothers of newly born children who present with fever and lower abdominal pain should be suspected of group-A streptococcal infection. Evaluation and treatment in hospital is indicated due to a sometimes fulminant course. When group-A streptococci are cultured again in a new pregnancy, eradication therapy during pregnancy or prophylactic treatment during birth should be considered to prevent recurrent infection.

[Vancomycin resistant enterococci in the Netherlands]. / Vancomycineresistente enterokokken in Nederland.

Enterococci (Enterococcus faecalis and Enterococcus faecium) are relatively avirulent enteric bacteria that usually only cause infections in immunocompromised patients. Antimicrobial treatment, however, is hampered as enterococci are intrinsically resistant to many antibiotics. For years, vancomycin was considered the last available antibiotic. Plasmid-mediated resistance against vancomycin among enterococci was first described in the nineteen-eighties and since then incidences of infection caused by vancomycin-resistant enterococci (VRE) have increased dramatically, especially in the United States. In 2000, three outbreaks of VRE occurred in hospitals in the Netherlands and a set of infection-control measures was proposed to limit further transmission. These measures were based on the simultaneous isolation of VRE from multiple patients. All three outbreaks were controlled by these measures and no new outbreaks in Dutch hospitals have been reported since then. Epidemiological studies have shown that hospital outbreaks on three continents were caused by a subpopulation of E. faecium, which is characterized by the presence of a potential virulence gene (variant esp) and resistance to amoxicillin. This 'hospital strain' of E. faecium has probably been prevalent within hospital settings for some time, but only became clinically relevant when it had acquired vancomycin-resistance. Current advice is to implement the set of infection control measures formulated in 2000, only in those patients colonized by amoxicillin-resistant VRE. The potential dangers of VRE were recently underlined by the proven transmission of the vancomycin-resistance gene from VRE to methicillin-resistant Staphylococcus aureus (MRSA) in two patients in the United States. It is in the interest of the patients that prevalence of VRE and MRSA in Dutch hospitals should be kept as low as possible.

[Increase in rate of resistance to fusidic acid among Staphylococcus aureus isolates from patients admitted with atopic dermatitis]. / Toename van resistentie tegen fusidinezuur van Staphylococcus aureus-isolaten bij opgenomen patiënten met constitutioneel eczeem.

To determine whether there has been an increase in the incidence of resistance to fusidic acid among Staphylococcus aureus isolates in the Netherlands, a retrospective study was carried out. The resistance pattern of S. aureus isolates from patients with atopic dermatitis at the Dermatology inpatient department of the University Medical Centre Utrecht was determined during the period 1995-2001. The rate of resistance increased from 9.7% to 23.4% during this period, whereas the rate of resistance of S. aureus to methicillin remained stable at around 0.5%. Prolonged topical use of fusidic acid is probably the main cause for the increase in fusidin resistance. Therefore it is advised to limit the use of fusidic acid for infected dermatitis to short periods of about two weeks, and only after sensitivity of the strain to fusidin has been confirmed.

[What is to be done with vancomycin-resistant enterococcal infections?]. / Wat te doen als men vancomycineresistente enterokokken aantreft?

Recently, three epidemics in Dutch hospitals were caused by vancomycin-resistant enterococci (VRE). Although the number of infections was small, spread of colonization was extensive and many infection control measures were necessary to prevent further spread. VRE are relatively avirulent bacteria. However, few, if any, antibiotics are available for treatment of infections caused by VRE and the genetic code for resistance may be transferable to other, more virulent, bacteria, such as methicillin-resistant Staphylococcus aureus (MRSA). Although colonization and infection with MRSA have become endemic in many surrounding countries, such a situation has been prevented in the Netherlands by employing an aggressive 'search and destroy' policy. Although many questions regarding the optimal approach of VRE remain unanswered, a similar policy as employed for MRSA will not be possible. In contrast to MRSA, colonization with VRE occurs in the open population, no populations with increased risk for colonization appear to be definable and colonization cannot be eradicated. Based on common sense, a differentiated approach seems indicated in which extensive infection control measures should only be implemented when spread of a single genotype has been demonstrated. A reference laboratory should be created for uniform genotyping.

[Epidemiologic increase of various genotypes of vancomycin-resistant Enterococcus faecium in a university hospital]. / Epidemische verheffing van verscheidene genotypen van vancomycineresistente Enterococcus faecium in een academisch ziekenhuis.

After a report of a possible relationship between an outbreak of vancomycin-resistant enterococci (VRE) in a nearby hospital and earlier admission of two of the patients with this VRE in the University Medical Centre of Utrecht (UMCU), the Netherlands, an extensive search for VRE carriers was started in the UMCU. In the study period of two months, VRE carriership was diagnosed in 51 patients in nine of the 11 wards investigated. Twenty-six patients in eight wards were colonized with the same VRE genotype as in the nearby hospital; spread was demonstrated in three wards. In addition, six patients of one ward were colonized with a second genotype and seven other patients with a third genotype, while 12 patients were carriers of a unique genotype. Most carriers were found in the internal medicine/nephrology and dialysis ward. Far-reaching measures (such as cohort nursing, admission stops, use of gowns and gloves, disinfection and restriction of use of vancomycin) taken in the four wards where spread was demonstrated, appeared effective but in three wards, spread was again demonstrated later. Frequent readmissions and transfers of patients appear to play an important part in this matter. None of the 51 colonized patients developed a serious VRE infection.

[Epidemic of methicillin-resistant Staphylococcus aureus due to the transfer of 2 Dutch burn patients from a hospital outside of the Netherlands; who suffers the consequences?]. / Epidemie van meticillineresistente Staphylococcus aureus door overname uit een buitenlands ziekenhuis van 2 Nederlandse brandwondpatiënten; wie draagt de gevolgen?

Two burns patients who were transferred to the Central Military Hospital Utrecht from a foreign hospital, were found to be colonised with MRSA. During their 5-week hospitalisation, 21 healthcare workers and one patient became colonised with the same MRSA strain, despite isolation precautions. The department was closed for 29 days; 96 admissions were cancelled and 1411 screening cultures for MRSA were performed. Colonised healthcare workers were temporarily unable to work and additional costs were incurred for disposables and cleaning procedures. The resultant bill for this outbreak was approximately [symbol: see text] 122,500. MRSA outbreaks occur in hospitals with some degree of regularity, but the strong dispersal during this epidemic was exceptional. The transfer of possible MRSA-colonised patients from hospitals outside of the Netherlands sometimes faces opposition due to the considerable demands it makes on a hospital's personnel, organisation and finances. If this were to be compensated, then the currently successful Dutch MRSA policy could be coupled with a willingness to accept patients from hospitals outside of the Netherlands.

New screening method to detect carriage of carbapenemase-producing Enterobacteriaceae in patients within 24 hours.

Rapid identification of patients colonized with carbapenemase-producing Enterobacteriaceae (CPE) is essential to prevent introduction and the spread of CPE in the hospital. This article presents the results of a new screening method to detect patients colonized with CPE within 24h after hospital admission. From high-risk patients rectal and throat swabs were collected and incubated overnight, after which DNA was isolated and tested for the most prevalent CPE genes (KPC, NDM, OXA-48, VIM and IMP) by a ligation-mediated real-time polymerase chain reaction. In 14 months 454 patients were screened; in six patients CPE were detected (carriage rate 1.3%).