Molecular characterization of colistin resistance genes in a high-risk ST101/KPC-2 clone of Klebsiella pneumoniae in a University Hospital of Split, Croatia.

Klebsiella pneumoniae carbapenemase-producing K. pneumoniae (KPC-KP) has become a major concern worldwide due to multidrug resistance and the ability to spread locally and globally. Infections caused by KPC-KP are great challenge in the healthcare systems because these are associated with longer hospitalization and high mortality. The emergence of colistin resistance has significantly reduced already limited treatment options. This study describes the molecular background of colistin-resistant KPC-KP isolates in the largest hospital in southern Croatia. Thirty-four non-duplicate colistin-resistant KPC-KP isolates were collected during routine work from April 2019 to January 2020 and from February to May 2021. Antimicrobial susceptibility was determined using disk diffusion, broth microdilution, and the gradient strip method. Carbapenemase was detected with an immunochromatographic test. Identification of blaKPC and mcr genes or mutations in pmrA, pmrB, mgrB, phoP, and phoQ genes were performed by polymerase chain reaction (PCR) and positive products were sequenced. Pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST) were used for epidemiological analysis. All isolates were multidrug-resistant, with colistin minimum inhibitory concentrations (MICs) from 4 to >16 mg/L, and all harbored blaKPC-2 and had a single point mutation in the mgrB gene resulting in a premature stop codon, with the exception of one isolate with four point mutations corresponding to stop codons. All isolates were negative for mcr genes. PFGE analysis identified a single genetic cluster, and MLST revealed that all isolates belonged to sequence type 101 (ST101). These results show emergence of the high-risk ST101/KPC-2 clone of K. pneumoniae in Croatia as well as appearance of colistin resistance due to mutations in the mgrB gene. Molecular analysis of epidemiology and possible resistance mechanisms are important to develop further strategies to combat such threats.

Serotype distribution and antimicrobial resistance of invasive Streptococcus pneumoniae isolates among Croatian adults during a fifteen-year period (2005-2019).

AIM: To assess serotype distribution, antibiotic resistance, and vaccine coverage against Streptococcus pneumoniae causing invasive infections in Croatian adults from 2005 to 2019. METHODS: In this retrospective study, invasive pneumococcal strains were collected through a microbiological laboratory network with country coverage >95%. Capsular typing was performed with the Quellung reaction. In vitro susceptibility testing was carried out according to the European Committee on Antimicrobial Susceptibility Twating guidelines. In macrolide-resistant isolates, the presence of ermB and mefA genes was evaluated. RESULTS: During the fifteen-year study period, 1123 invasive pneumococcal isolates were obtained. The most prevalent serotypes were 3, 14, 19A, 9V, 7F, and 23F, comprising 60% of all invasive pneumococcal isolates. Serotype 3 was the dominant serotype, with the highest prevalence in patients ≥65 years of age. Penicillin susceptibility, increased exposure was 18.6%, mostly associated with serotypes 14 and 19A. Resistance to penicillin was low (<1%). Macrolide resistance was 23%, mostly associated with serotypes 14, 19A, and 19F. The coverage with 13-valent conjugate vaccine (PCV13) and 23-valent polysaccharide vaccine (PPV23) was 80.2% and 93.6%, respectively. CONCLUSIONS: The incidence of invasive pneumococcal disease in adults is highest in patients ≥65 years of age. Penicillin susceptibility, increased exposure and macrolide resistance were mostly associated with serotypes 14 and 19A. PCV13 and PPV23 provide very high serotype coverage. Future studies should evaluate the effects of the 10-valent vaccine, introduced in the Croatian National Immunization Program in June 2019, on serotype distribution and antibiotic resistance rates.

Altered Gut Microbiota Is Present in Newly Diagnosed Pediatric Patients With Inflammatory Bowel Disease.

BACKGROUND AND AIMS: Clinical and experimental data suggest that gut microbiota plays an important role in the pathogenesis of inflammatory bowel disease (IBD). The aim of this study was to determine intestinal microbiota in newly diagnosed patients with IBD and to compare it with patients' healthy siblings who share same genetic and environmental background and to healthy unrelated controls. METHODS: Molecular approach targeting 16S ribosomal RNA was employed for analyzing the gut microbiota of participants' stool samples. Terminal restriction fragment length polymorphphism analysis was performed. RESULTS: Newly diagnosed pediatric patients with IBD (n = 19, 68.4% Crohn disease [CD], mean age 14.8 ±â€Š0.65 years), their unaffected healthy siblings (n = 20, mean age 12.8 ±â€Š0.85 years), and unrelated healthy controls (n = 19, mean age 10.7 ±â€Š0.8 years) were included. Microbial diversity differed significantly between IBD patients, healthy siblings, and healthy controls (P = 0.018 for MspI digestion, P = 0.013 for HhaI digestion). No significant difference in microbial diversity was found between healthy siblings and healthy controls. In patients reduced presence of genus Eubacterium, Lactobacillus, Enterobacter and Clostridium, and increased presence of genus Streptococcus, Prevotella and Escherichia, compared with healthy siblings and healthy controls, was found. CONCLUSION: Newly diagnosed pediatric patients with IBD show significantly less diverse microbiota and microbial composition compared with healthy siblings and healthy controls.

Impact of antibiotic consumption on the carriage of antibiotic-resistant bacteria by school children.

BACKGROUND: Antibiotic consumption in the paediatric population is one of the key drivers of the emergence and spread of antimicrobial resistance, which is a serious global threat to public health and clinical medicine. The aims of this study were to investigate systemic antibiotic consumption in school children and to assess the associations among antibiotic consumption, carriage rate and resistance of respiratory pathogens residing in the upper respiratory tract mucosa. METHODS: In this prospective study, throat and nasopharyngeal swabs from 450 school children, 6-15 years of age (225 healthy children and 225 patients who were ambulatory treated for upper respiratory tract infection), were processed in 2014 in Rijeka, Croatia, and clinical data were obtained via a questionnaire. RESULTS: In total, 17% of the children had consumed an antibiotic in the previous 6 months, including 7% of the healthy children and 27% of the acutely ill patients. The most commonly prescribed antibiotics were amoxicillin (26%), amoxicillin with clavulanic acid (26%) and macrolides (18%). Respiratory pathogens were more frequently isolated from children who had consumed an antibiotic in the previous 6 months [odds ratio (OR) 3.67, P < 0.001]. Antibiotic-resistant bacteria were also more frequent in children who had been exposed to antibiotics (OR 5.44, P < 0.001). CONCLUSIONS: Penicillins are the most frequently used antibiotics among school children. The results of this study demonstrate that antibiotic consumption is linked with higher carriage rates and resistance rates of respiratory tract pathogens. Therefore, rational use of antibiotics could prevent the emergence and spread of resistant bacteria.

Distribution of Clostridium difficile PCR ribotypes and high proportion of 027 and 176 in some hospitals in four South Eastern European countries.

While Clostridium difficile epidemiology is well documented in many European countries, data are largely missing for South Eastern European region. Here we report the PCR ribotype distribution of 249 C. difficile isolates received for typing from six hospital settings from Croatia, Bosnia and Herzegovina, Republic of Macedonia and Serbia in time period from 2008 to 2015. Twenty-four PCR ribotypes were detected. The majority of strains from Bosnia and Herzegovina and Serbia belonged to PCR ribotype 027 (65.8%). Other three dominating PCR ribotypes were 176 (18 strains; Croatia), 001/072 (15 strains; all countries) and 014/020 (15 strains; all countries).

Rational Therapy of Urinary Tract Infections in Children in Croatia

Resistance to chemotherapeutics used in the treatment of urinary tract infection is increasing throughout the world. Taking into account clinical experiences, as well as current bacterial resistance in Croatia and neighboring countries, the selection of antibiotic should be the optimal one. Treatment of urinary tract infection in children is particularly demanding due to their age and inclination to severe systemic reaction and renal scarring. If parenteral antibiotics are administered initially, it should be switched to oral medication as soon as possible. Financial aspects of antimicrobial therapy are also very important with the main goal to seek the optimal cost/benefit ratio. Financial orientation must appreciate the basic primum non nocere as a conditio sine qua non postulate as well.

Sequence types 235, 111, and 132 predominate among multidrug-resistant pseudomonas aeruginosa clinical isolates in Croatia.

A population analysis of 103 multidrug-resistant Pseudomonas aeruginosa isolates from Croatian hospitals was performed. Twelve sequence types (STs) were identified, with a predominance of international clones ST235 (serotype O11 [41%]), ST111 (serotype O12 [15%]), and ST132 (serotype O6 [11%]). Overexpression of the natural AmpC cephalosporinase was common (42%), but only a few ST235 or ST111 isolates produced VIM-1 or VIM-2 metallo-ß-lactamases or PER-1 or GES-7 extended-spectrum ß-lactamases.

Understanding and Practices of Oral Hygiene in the Intensive Care Units: Perspectives of Medical Staff at Two University Hospital Centers.

Objective: This study assesses the knowledge, practices, and attitudes of medical staff in intensive care units (ICUs) regarding oral hygiene care for critically ill, bedridden patients. Material and methods: A cross-sectional study included 65 employees from the Intensive Care Units of the Sestre Milosrdnice Clinical Hospital Centre (CHC SM) and the Clinic for Anesthesiology and Intensive Care at the University Clinical Hospital Centre Zagreb (CHC ZG). A self-administered questionnaire was used to assess knowledge, methods, frequency, and attitudes towards oral care for mechanically ventilated patients. The data were examined through descriptive statistical methods, presented in terms of proportions (percentages). For the purpose of comparing the feedback across the two hospital centers and different educational backgrounds, the Chi-square and Fisher's exact tests were employed. Results: Results of a survey of 65 participants (18 from CHC SM and 47 from CHC ZG) revealed a notable disparity in oral hygiene knowledge, with graduate nurses displaying the highest proportion of adequate knowledge (100%) and regular nurses showing the least (30.3%) (p<.001). Although the execution of oral care practices did not vary significantly among the groups, graduate nurses performed oral care more frequently (80% vs. baccalaureate technicians 33.33% and nurses 57.6%, three or more times a day) and demonstrated better proficiency in both mechanical (p=.005) and chemical (p<.001) biofilm management compared to their counterparts. No significant difference was observed in the delivery of oral care to orotracheally intubated patients across different educational levels (p=.127). However, a marked difference was noted in the perception of being adequately trained for such care, with nurses feeling less prepared (12.1%, p<.001). Despite these variances, all respondents recognized the importance of oral hygiene, thus showing a strong dedication to oral health care. Conclusions: This study highlights variability in ICU oral hygiene practices and points to the importance of standardized care protocols and improved training for healthcare staff.

Perspectives of primary care physicians on academic detailing for antimicrobial stewardship: feasibility and impact assessment.

OBJECTIVE: To understand primary care physicians' perspectives on academic detailing from an antimicrobial stewardship team to combat antibiotic overuse for upper respiratory infections and bronchitis in the COVID-19 era, which will help prevent avoidable outpatient visits. METHODS: In this prospective study, 14 female Croatian physicians completed standardized qualitative interviews using a semi-structured guide. The data were analyzed using inductive methodology based on reflexive thematic analysis. We used a theoretically informed approach based on a conceptual framework of healthcare intervention implementability focused on three domains: acceptability, fidelity, and feasibility. RESULTS: We identified six key themes highlighting barriers to changing prescribing practices, with patient pressure and specialist recommendations having an impact on the effectiveness of academic detailing. Despite challenges, primary care physicians described appreciation of direct interaction with evidence-based practices and reported usefulness, effectiveness, and further need for academic detailing. CONCLUSION: This study highlights the complex dynamics involved in implementing healthcare interventions and provides valuable insights for enhancing strategies directed at improving antibiotic prescribing practices. Specifically, our findings emphasize factors influencing behavior changes in physicians' antibiotic prescribing. The authors advocate for a collaborative approach involving community and hospital-based professionals to provide tailored guidance and address questions, ultimately improving prescribing practices.

Pseudomonasaeruginosa antimicrobial susceptibility profiles, resistance mechanisms and international clonal lineages: update from ESGARS-ESCMID/ISARPAE Group.

SCOPE: Pseudomonas aeruginosa, a ubiquitous opportunistic pathogen considered one of the paradigms of antimicrobial resistance, is among the main causes of hospital-acquired and chronic infections associated with significant morbidity and mortality. This growing threat results from the extraordinary capacity of P. aeruginosa to develop antimicrobial resistance through chromosomal mutations, the increasing prevalence of transferable resistance determinants (such as the carbapenemases and the extended-spectrum ß-lactamases), and the global expansion of epidemic lineages. The general objective of this initiative is to provide a comprehensive update of P. aeruginosa resistance mechanisms, especially for the extensively drug-resistant (XDR)/difficult-to-treat resistance (DTR) international high-risk epidemic lineages, and how the recently approved ß-lactams and ß-lactam/ß-lactamase inhibitor combinations may affect resistance mechanisms and the definition of susceptibility profiles. METHODS: To address this challenge, the European Study Group for Antimicrobial Resistance Surveillance (ESGARS) from the European Society of Clinical Microbiology and Infectious Diseases launched the 'Improving Surveillance of Antibiotic-Resistant Pseudomonas aeruginosa in Europe (ISARPAE)' initiative in 2022, supported by the Joint programming initiative on antimicrobial resistance network call and included a panel of over 40 researchers from 18 European Countries. Thus, a ESGARS-ISARPAE position paper was designed and the final version agreed after four rounds of revision and discussion by all panel members. QUESTIONS ADDRESSED IN THE POSITION PAPER: To provide an update on (a) the emerging resistance mechanisms to classical and novel anti-pseudomonal agents, with a particular focus on ß-lactams, (b) the susceptibility profiles associated with the most relevant ß-lactam resistance mechanisms, (c) the impact of the novel agents and resistance mechanisms on the definitions of resistance profiles, and (d) the globally expanding XDR/DTR high-risk lineages and their association with transferable resistance mechanisms. IMPLICATION: The evidence presented herein can be used for coordinated epidemiological surveillance and decision making at the European and global level.

First Report of Campylobacter jejuni Strains Belonging to ST-21 Clonal Complex Isolated from Human, Poultry and Wild Birds in Croatia: Antimicrobial Resistance and Genetic Distance.

In the era of growing antimicrobial resistance, a threat affecting humans, endangering animals, as well as livelihoods and food security worldwide, we wanted to find possible explanations for its continuous spread from a new perspective. The ubiquity of resistance genes requires a One Health approach to finding the explanations for continuous AMR spread. The natural transformability of Campylobacter jejuni, its high incidence of infections, and emerging resistance worldwide inspired us to choose C. jejuni ST-21CC to be our pathogen for analyzing its contribution and connection to the cycle of AMR dissemination. ST-21CC is known as a generalist among humans and broilers, the most prevalent lineage worldwide, but it is rarely found in wild birds. Emerging in wild birds, genetic relatedness and similar resistance profiles were expected. We analyzed 23 Croatian C. jejuni strains belonging specifically to ST-21CC from humans, broilers, and wild birds. The genomic data obtained through whole genome sequencing and phenotypic susceptibility data of strains were compared. Our findings suggest high fluoroquinolone resistance in ST-21CC strains, with more diverse genetic backgrounds in wild birds. Intriguing were three isolates of ST-822 (from human and storks), sharing a similar genetic fingerprint.

Gut Microbiota Composition Changes following Discontinuation of Exclusive Enteral Nutrition in Children with Crohn's Disease.

This study aims to determine changes in the intestinal microbiota of children with Crohn's disease (CD) before and during exclusive enteral nutrition (EEN) and after its discontinuation. A total of 14 newly diagnosed children with CD (median age 16.0 years; 43% female) were included in this study. Patients were initially treated with EEN and were followed for one year after EEN discontinuation. Stool samples were taken at the time of diagnosis (before EEN introduction), the second day of EEN, the last day of EEN, and every two months for one year after the discontinuation of EEN. A molecular approach targeting 16S ribosomal RNA was used for analysing the gut microbiota. No change was found in the Shannon diversity index before, during, and after EEN cessation (HhaI-digestion p = 0.82; MspI-digestion p = 0.87). According to the PCO, on the basis of the dissimilarity matrices of OTUs, a clear separation of patients at different time points, forming two clusters (before and during EEN as opposed to after EEN), was evident. No clear separation was noted between patients who achieved sustained remission as opposed to those who did not achieve sustained remission during EEN and at the follow-up. In conclusion, a distinct change in the microbiota composition already occurred after two months of EEN discontinuation and remained mostly unchanged over a year of follow-up.

Prediction of unfavorable outcomes in community-acquired bacteremia by SIRS, SOFA and qSOFA scores.

BACKGROUND: Sepsis diagnostic and prognostic scoring systems have changed over time. It remains uncertain which scoring system is the best predictor of unfavorable outcomes. We aimed to evaluate prediction of community-acquired bacteremia (CAB) outcomes using on-admission systemic inflammatory response syndrome (SIRS), sequential organ failure assessment (SOFA) and quick sequential organ failure assessment (qSOFA). METHODS: We present a retrospective observational cohort study of consecutive adult patients hospitalized with CAB over ten years. SIRS, qSOFA and SOFA scores calculated on admission were dichotomized as ≥2 or 0-1. Raw and adjusted incidence of a composite unfavorable outcome (death, septic shock, invasive mechanical ventilation, extra-corporeal membrane oxygenation, renal replacement therapy) over 35 days were compared. RESULTS: Among 1930 patients, 1221 (63.3%) had SIRS, 196 (10.2%) had qSOFA, and 1117 (57.9%) had SOFA≥2. Respective raw and adjusted probabilities of the outcome were similar. Incidence for qSOFA≥2 was high (41.3%) and still considerable for qSOFA 0-1 (5.4%). SOFA≥2 indicated higher risk than SIRS≥2 (14.7% vs. 12.4%), while SOFA 0-1 indicated lower risk than SIRS 0-1 (1.2% vs. 3.1%). This relationship between SOFA and SIRS was also observed in patients with qSOFA 0-1. CONCLUSIONS: qSOFA≥2 was associated with highest probability of unfavorable outcome, but dichotomized SOFA was more precise at high vs. low-risk distinction. Consecutive use of dichotomized qSOFA and SOFA on admission of adults with CAB enables fast and reliable identification of patients at high (qSOFA≥2, risk ~≥35%), moderate (qSOFA 0-1, SOFA≥2, risk ~10%), and low risk (qSOFA 0-1, SOFA 0-1, risk 1-2%) of subsequent unfavorable events.

Tricuspid Valve Endocarditis Due to Methicillin-Resistant Staphylococcus aureus in a Previously Healthy Young Patient without a Drug Abuse History: A Case Report and a Review of the Literature.

Right-sided infective endocarditis due to methicillin-resistant Staphylococcus aureus (MRSA) is strongly associated with intravenous drug abuse, congenital heart disease, or previous medical treatment and is rare in healthy patients without a history of drug abuse. Here, we present a case of an 18-year-old male with no drug abuse history and no medical burden who was diagnosed with MRSA tricuspid valve endocarditis. Due to initial symptoms which indicated community-acquired pneumonia and radiological finding of interstitial lesions, empiric therapy with ceftriaxone and azithromycin was started. After the detection of Gram-positive cocci in clusters in several blood culture sets, endocarditis was suspected, and flucloxacillin was added to the initial therapy. As soon as methicillin resistance was detected, the treatment was switched to vancomycin. Transesophageal echocardiography established the diagnosis of right-sided infective endocarditis. A toxicological analysis of hair was carried out, and no presence of narcotic drugs was found. After six weeks of therapy, the patient was fully recovered. Exceptionally, tricuspid valve endocarditis can be diagnosed in previously healthy people who are not drug addicts. As the clinical presentation commonly resembles a respiratory infection, a misdiagnosis is possible. Although MRSA rarely causes community-acquired infections in Europe, clinicians should be aware of this possibility.

Association of Gut Lachnospiraceae and Chronic Spontaneous Urticaria.

(1) Background: Chronic spontaneous urticaria (CSU) has been linked to the dysbiosis of the gut microbiota. Furthermore, various studies have highlighted the anti-inflammatory properties of short-chain fatty acids (SCFAs), whose production is primarily regulated by the gut microbiota. However, only a few studies have investigated the role of major SCFA producers, such as Lachnospiraceae, in skin inflammatory diseases. (2) Goal: This study aimed to compare the abundance of Lachnospiraceae between CSU patients and healthy controls (HCs). (3) Material and methods: In this case-control study, 16S rRNA sequencing was performed to compare the composition of the gut microbiome between 22 CSU patients and 23 HCs. (4) Results: Beta-diversity revealed significant clustering (p < 0.05) between the CSU patients and HCs. Alpha diversity in the CSU group was significantly decreased according to the Evenness index (p < 0.05). The linear discriminant analysis effect size (LEfSe) identified the significant depletion of the Lachnospiraceae family in CSU patients. (5) Conclusion: Our study revealed the dysbiosis of the gut microbiota in CSU patients, including decreased levels of Lachnospiraceae members, responsible for SCFA production, suggesting that SCFAs may contribute to immune dysfunction in the pathogenesis of CSU. We speculate that the modulation of SCFAs could serve as a prospective additional option in CSU treatment.

[Bloodstream infections after liver and hematopoietic stem cell transplantation]. / Infekcije krvotoka u bolesnika nakon transplantacije jetre i krvotvornih maticnih stanica.

The aim of this retrospective study was to evaluate and compare the incidence, timing and etiology of bloodstream infections (BSIs) in patients treated with liver-(LT) or hematopoietic stem cell transplantation (HSCT) in a single institution. We evaluated 280 consecutive transplantations over a period of 34 months. Our results demonstrated 84 episodes of BSIs (47 in LT patients and 37 in HSCT patients) at a median of 28 days post-transplantation. Relative incidence of 34.6 and 29.4 BSI episodes per 100 LT and HSCT patients, respectively, did not differ significantly between the two groups (p = 0.52). BSIs in HSCT patients occurred significantly earlier (p = 0.003) than in LT patients. The recently described reemergence of gram-negative (GN) pathogens as causative agents of BSIs in these patients was confirmed: GN bacilli were the predominant isolates in the LT group, responsible for 58.5% of BSIs and a very frequent (39%) cause of BSIs in the HSCT group. A higher incidence of resistant enterobacteriaceae producing extended spectrum beta-lactamases was found in isolates from LT patients compared to HSCT patients. In both groups, Pseudomonas aeruginosa was the most difficult to treat organism, with 57% of these isolates in LT patients and 44% in HSCT patients being resistant to carbapenems. To conclude, BSIs were confirmed to be important infectious complications of both LT and HSCT. Surveillance and analysis of bacteria causing bloodstream and other serious infections in transplanted patients remain the main prerequisites for planning interventions regarding prevention and treatment of infections in these patients.

Resistome Analysis of Campylobacter jejuni Strains Isolated from Human Stool and Primary Sterile Samples in Croatia.

Campylobacteriosis represents a global health challenge due to continuously increasing trends of antimicrobial resistance in Campylobacter jejuni. C. jejuni can sometimes cause life-threatening and severe systematic infections (bacteremia, meningitis, and other extraintestinal infections) with very few antibiotics left as treatment options. Bearing in mind that C. jejuni is the predominant species in humans, in this paper, we present a study of the C. jejuni differences in antimicrobial resistance and genotype distribution between strains isolated from stool and primary sterile sites. We compared the genomic data obtained through whole genome sequencing (WGS) and phenotypic susceptibility data of C. jejuni strains. Once antimicrobial susceptibility testing of C. jejuni strains was carried out by the broth microdilution method for six of interest, results were compared to the identified genotypic determinants derived from WGS. The high rate of resistance to fluoroquinolones presented in this study is in accordance with national surveillance data. The proportion of strains with acquired resistance was 71% for ciprofloxacin and 20% for tetracycline. When invasive isolates were analysed separately, 40% exhibited MIC values of ciprofloxacin higher than the ECOFFs, suggesting a lower flouroquinolone resistance rate in invasive isolates. All isolates demonstrated wilde-type phenotype for chloramphenicol, erythromycin, gentamicin, and ertapenem. A special focus and review in this study was performed on a group of C.jejuni strains found in primary sterile samples. Apart from demonstrating a lower resistance rate, these isolates seem genetically more uniform, showing epidemiologically more homogenous patterns, which cluster to several clonal complexes, with CC49 being the most represented clonal complex.

Antibiotic Prescribing Habits and Antimicrobial Resistance Awareness of Dental Practitioners in Primorsko-Goranska County, Croatia.

Purpose: The goal of this study was to investigate the differences in dentists' knowledge, attitudes, and practice regarding antibiotic use and resistance among two areas of Primorsko-Goranska County (P-GC), Croatia. Materials and Methods: A cross-sectional study based on a structured questionnaire that was given to 230 dental practitioners in outpatient settings of P-GC in 2018. Results: The overall response rate was 68.3% (157/230) and 72.2% (83/115) in the city of Rijeka and 64.3% (74/115) in the rest of P-GC. Dentists from two areas of P-GC held similar knowledge about prescribing antibiotics and attitudes regarding antibiotic use (p > 0.05). Most of the dental practitioners chose penicillins (65.0% amoxicillin with clavulanic acid and 33.1% amoxicillin) as the first-choice antibiotic in patients with no medical allergies. The trend of prescribing amoxicillin decreases with the age of the dentists (p = 0.046). Clindamycin (86.6%) was the first choice for patients allergic to penicillin. Postgraduate education changed the attitude toward taking more time to consider whether or not an antibiotic is needed. Croatian dentists had a high awareness of antimicrobial resistance (99.4%). The most common situations for which dentists would prescribe antibiotics were periapical abscess (84.7%), periodontal abscess (72.6%), and implant placement (59.9%). Patient request or expectation (43.4%) and treatment uncertainty (41.5%) were found to be the main factors for prescribing antibiotics with more frequency. Conclusions: Although there is a high level of antimicrobial resistance awareness among dental practitioners, there is still too much overuse of antibiotics and personal responsibility for prudent antibiotic use should be increased. The results of this study indicate that antibiotics are frequently prescribed for indications where surgical treatment should be the first option and the broad spectrum antibiotic is the preferred treatment option.

Meningitis caused by Campylobacter jejuni: a case presentation and literature review.

Objectives: Campylobacter jejuni is one of the most common causative agents of gastroenteritis; however C. jejuni meningitis is rarely described. Therefore, little is known about its epidemiology, clinical presentation, diagnostic methods, treatment, and outcomes.Methods: In this paper, we report a case of an adult patient with C. jejuni meningitis. In addition, we reviewed 16 cases of C. jejuni published since 1980.Results: We described a 62-year-old immunocompromised patient with meningitis and gastroenteritis in whom C. jejuni was rapidly detected in cerebrospinal fluid (CSF) using 16S rDNA, while blood culture yielded the same pathogen with 48 h delay. Following 21 day-long treatment with meropenem, our patient fully recovered. Literature review revealed that C. jejuni meningitis is mainly described in newborns and adults with central nervous system comorbidities and it is most frequently detected by bacterial cultures.Conclusion: There are no clear recommendations for antimicrobial treatment of C. jejuni meningitis, but meropenem seems to be a safe and effective choice. High hopes are placed in new, broad-range culture-independent molecular methods that enable rapid pathogen detection, even in case of negative cultures.

Healthy Siblings of Children With Crohn's Disease Exhibit More Rapid Changes in Microbiota Composition as a Response to Exclusive Enteral Nutrition.

BACKGROUND: The aim of this study was to determine the impact of exclusive enteral nutrition (EEN) on the microbiota composition of the newly diagnosed Crohn's disease (CD) patients and to determine the effect of EEN received for 2 days in siblings of patients with CD. METHODS: Newly diagnosed pediatric CD patients (n = 17) and unaffected healthy siblings (n = 10) participated in the study. In CD patients, stool samples were collected at 3 time points: prior to therapy introduction, the second day of EEN therapy, and the last day of EEN therapy. In healthy siblings, stool samples were collected before the introduction of EEN and the second day of EEN. Molecular approach targeting 16S ribosomal RNA was used for analyzing the gut microbiota of participants' stool samples. RESULTS: There was no significant difference in microbial diversity between children with CD and healthy siblings before EEN (P = .127 for HhaI digestion; P = .604 for MspI digestion) as opposed to the second day of EEN (P = .006 HhaI digestion; P = .023 MspI digestion). In healthy controls, significant changes in microbiota composition were apparent by the second day of EEN, contrary to children with CD, in whom similar changes in microbiota composition were apparent on the last day of EEN. CONCLUSION: EEN leads to significant microbiota changes in both healthy children and children with CD. Changes in microbiota composition occur more rapidly in healthy children, whereas in children with CD, significant changes were detected at the end of EEN.