How is post-mortem microbiology appraised by pathologists? Results from a practice survey conducted by ESGFOR.

Post-mortem microbiology (PMM) is an important tool in forensic pathology, assisting to determine the cause and manner of death. However, there is a lack of standardisation of PMM sampling. In order to get a better insight into the methods used, the available technical options and developmental needs, ESCMID Study Group for Forensic and Postmortem Microbiology (ESGFOR) members designed a survey aimed at pathologists regarding common practices of PMM in clinical and forensic autopsies. Multiple choice questions were developed based on Cumulative Techniques and Procedures in Clinical Microbiology (Cumitech). The questionnaire was sent to pathologists mainly across Europe and Turkey using SurveyMonkey. The survey had 147 respondents. Although all pathologists were aware of the existence of PMM, 39% (19/49) of the participants were not using it. The three main indications for PMM were: (i) clinical suspicion of an infection not confirmed antemortem (83%), (ii) infectious signs at autopsy (83%) and (iii) as part of a standard protocol for foetal/perinatal or paediatric death (67%). Almost 80% of the participants using PMM stated taking 1-10 samples per case. Of the requested examinations, a general bacteriological culture (96%) and a specific polymerase chain reaction (PCR) assay for a particular infectious agent (34%) were most popular. The most frequent samples were: heart blood (66%), peripheral femoral blood (49%), spleen (64%) and lung (56%). Eighty-nine percent of the participants considered PMM a useful resource when investigating the cause of death. Although there are some common uses, this survey indicates that there is a need for improvement towards standardising sampling procedures in PMM.

Palaeomicrobiology meets forensic medicine: time as a fourth-dimension for the crime scene.

The unrelenting progress of laboratory techniques is rapidly unleashing the huge potential of palaeomicrobiology. That bodies are often found in poor condition is common to both palaeomicrobiology and forensic medicine, and this might stimulate them towards a joint quest to extract reproducible data for reliable specimens.

Interference of confounding factors on the use of (1,3)-beta-D-glucan in the diagnosis of invasive candidiasis in the intensive care unit.

Invasive fungal infections (IFIs) are an increasing problem in intensive care units (ICUs), and conventional diagnostic methods are not always reliable or timely enough to deliver appropriate antimicrobial therapy. The dosage of fungal antigens in serum is a promising diagnostic technique, but several confounding factors, such as treatment with immunoglobulins (Ig), albumin, or antifungals, could interfere with the correct interpretation of the (1,3)-beta-D-glucan (BG) assay. This study assessed the reliability of the BG assay and the influence of timing and dosage of major confounding factors on circulating levels of IFI biomarkers. 267 ICU patients who underwent a BG assay were retrospectively studied. The timing and dosage of albumin, use of azole treatment, and infusions of intravenous IgG, red blood cells, concentrated platelets, and frozen plasma were analyzed to find possible correlations with the BG results. The sensitivity and specificity of the BG assay were calculated. The BG test in serum showed high sensitivity (82.9 %) but low specificity (56.7 %). The optimal cut-off for the test was 95.9 pg/mL. The mean BG level in proven invasive candidiasis was around 400 pg/mL. The only factor that was found to significantly confound (p < 0.05) the diagnostic performance of the BG assay was the administration of more than 30 g of albumin within 2 days prior to BG testing. The BG assay remains a useful diagnostic test in ICU patients and the levels of BG are useful in evaluating the positive predictive value of this biomarker. The only confounding factor in our study was the use of albumin.

A case of Beauveria bassiana keratitis confirmed by internal transcribed spacer and LSU rDNA D1-D2 sequencing.

We describe a case of fungal keratitis due to Beauveria bassiana in a farmer with Fuchs' dystrophy, treated with amphotericin B. Surgery with penetrating keratoplasty was necessary to resolve the lesions. Susceptibility testing and molecular sequencing permitted the identification and treatment of this rare aetiological agent of invasive fungal disease.

Diversity of carbapenemases in clinical isolates of Enterobacteriaceae in Croatia--the results of a multicentre study.

Since the first carbapenem-resistant Klebsiella pneumoniae strain was isolated in 2008, Enterobacteriaceae with reduced susceptibility to one or more carbapenems have emerged sporadically in different geographical regions in Croatia. These observations gave rise to a multicenter study on carbapenem resistance in Enterobacteriaceae from Croatia. Fifty-seven carbapenem-non-susceptible strains of Enterobacteriaceae were collected during 2011-2012 from four large hospital centres in Croatia. Overall, 36 strains produced VIM-1 ß-lactamase, three produced NDM-1, and one produced KPC-2. A high degree of clonal relatedness was observed in Enterobacter cloacae and Citrobacter freundii strains, in contrast to K. pneumoniae strains. BlaVIM genes were located within class1 integron which contained genes encoding resistance to aminoglycosides (aacA4 ). The study found strong association between blaVIM and qnrB6 and between blaNDM and qnrA6 genes.

Barriers to the vaccination of children and adolescents and possible solutions.

The benefits of vaccination are clearly demonstrated by the eradication or enormous decline in the incidence of many vaccine-preventable diseases, but the coverage of many highly recommended vaccines is still frequently inadequate and children continue to suffer from diseases that could have been prevented. The main aim of this paper is to discuss the recognized barriers to the vaccination of children and adolescents confronting national health systems, providers and parents, and the ways in which they can be overcome. Most of the problems underlying limited vaccination coverage among children are due to a lack of understanding on the part of healthcare providers and parents, which underlines the need for educational programmes specifically addressed to each of these groups. It is also essential that all of the physicians providing immunization develop approaches that acknowledge parents' concerns and respectfully try to correct any misinformation. Other means of extending vaccine coverage include the implementation of adequate systems for recording vaccine administration and the activation of effective reminder/recall systems, the provision of immunization services in some medical care specialties or by integrating healthcare sites, and the elimination or reduction of all the problems that currently limit access to vaccination services. However, it will take the combined efforts of healthcare systems and providers to pull down all of the barriers.

Klebsiella pneumoniae harbouring OXA-48 carbapenemase in a Libyan refugee in Italy.

A carbapenem-resistant Klebsiella pneumoniae was isolated from a blood-culture of an inpatient from Libya, hospitalized in the intensive-care unit of Negrar Hospital, Italy. The clinical isolate carried the following ß-lactamase genes, bla(TEM -1), bla(SHV -11), bla(OXA -1), bla(CTX -M-15) and bla(OXA -48), respectively. The bla(OXA -48) gene was inserted in the Tn1999.2 transposon type, carried on a conjugative, 60-kilobase plasmid, that presented an L/M backbone, hosted by a multidrug-resistant ST 101 K. pneumoniae strain. Our report highlights the international transfer of bla(OXA -48) gene and the importance of screening measures of multidrug-resistant Enterobacteriaceae.

Prevalence of plasmid-mediated quinolone resistance determinants in Enterobacteriaceae strains isolated in North-East Italy.

We investigated the prevalence of plasmid-mediated quinolone resistance genes in 756 clinical isolates of Enterobacteriaceae originating from Microbiology Diagnostic Laboratories of North-East Italy. Five point zero two percent of isolates carried a qnr determinant while the aac(6')-Ib-cr determinant was detected in 9·25% of isolates. We also investigated the association between the plasmid-mediated quinolone resistance and the beta-lactamase genes, and characterized the plasmids carrying these determinants of resistance.

Rapid molecular technique analysis of a KPC-3-producing Klebsiella pneumoniae outbreak in an Italian surgery unit.

The rapid emergence of KPC-producing Klebsiella pneumoniae has become a serious problem in health-care settings, increasing in frequency worldwide. These infections are worrisome, since the antimicrobial treatment options for infections due to multidrug-resistant strains are very limited, and outbreaks must be rapidly detected and controlled. A semi-automated, repetitive-sequence-based PCR (rep-PCR) instrument (DiversiLab system) was evaluated in comparison with the pulse-field gel electrophoresis (PFGE) and multilocus sequence typing to investigate the outbreak of KPC-producing K. pneumoniae in a surgery unit at the University Hospital of Verona, Italy, as a rapid method for outbreak investigations. A selection of seven epidemiologically related K. pneumoniae showing resistance to carbapenem and three epidemiologically unrelated K. pneumoniae isolates were collected from patient with hospital-acquired infection. Among the epidemiologically related isolates, PFGE and Rep-PCR identified a unique pattern with more than 90% of homology. The concordance between DiversiLab and PFGE results confirmed the usefulness of rapid molecular techniques to investigate outbreaks due to multidrug-resistant bacteria. Moreover, this result could meet the international need for a harmonised typing tool, allowing the implementation of strict control measures to prevent dissemination of these organisms in health-care settings.

Outbreak of linezolid-resistant Staphylococcus haemolyticus in an Italian intensive care unit.

We report an outbreak of linezolid-resistant Staphylococcus haemolyticus strains (MIC 32 mg/L) in patients admitted to the Verona University Hospital Intensive Care Unit. The strains proved to be clonally related at pulsed field gel electrophoresis. All the strains showed the G2576T mutation responsible for linezolid-resistance and retained their resistance even after several passages on antibiotic-free medium. After a decade of linezolid use, multifocal emergence of linezolid resistance in coagulase-negative staphylococci has become an important matter of concern and mandates stricter control over the use of this antibiotic in order to preserve its clinical utility.

Description and plasmid characterization of qnrD determinants in Proteus mirabilis and Morganella morganii.

We investigated the presence of qnrC and qnrD among 756 non-replicate Enterobacteriaceae isolated in Italy, selected for being non-susceptible to fluoroquinolones and/or resistant to third-generation cephalosporins. Four Proteus mirabilis and one Morganella morganii (0.66% of the total) presented a qnrD gene, located in a 2687-base-pair plasmid that was entirely sequenced. The plasmid is un-typable, and contains no known coding region other than qnrD. That the qnrD gene was found in four unrelated P. mirabilis and in one M. morganii isolate might suggest a frequent association of this gene with the tribe Proteeae.

Healthcare workers and influenza vaccination: an ERS-ESCMID Web-based survey.

We performed a Web-based survey on attitudes and uptake of H1N1 influenza vaccination among members of two European societies, namely the European Respiratory Society and the European Society of Clinical Microbiology and Infectious Diseases. A multidisciplinary panel developed a questionnaire that examined physicians' and members' knowledge, attitudes and practice about seasonal and pandemic (H1N1) influenza vaccination. In all, 1334 healthcare workers from 83 countries (785 men and 549 women, mean age 45 ± 7 years) accessed and completed the survey. Safety concerns about vaccines was the main reason reported by 451/1285 respondents for not being vaccinated. More than 30% of 1282 respondents considered the management of communication on the flu pandemic by health authorities to be insufficient. The results of this survey should help health authorities to better design future steps for the successful vaccination of healthcare workers.

A novel VIM-type metallo-beta-lactamase (VIM-14) in a Pseudomonas aeruginosa clinical isolate from a neonatal intensive care unit.

A Pseudomonas aeruginosa highly resistant to carbapenems was isolated in a neonatal intensive care unit in Palermo, Italy. The strain was found to carry a novel VIM-type enzyme, classified as VIM-14. The novel enzyme differs from VIM-4 in a G31S mutation. VIM-14 was harboured in a class 1 integron with a new organization. The integron carried the genes aac7, blaVIM-14, blaOXA-20 and aac4 in that order.

A European survey of antibiotic management of methicillin-resistant Staphylococcus aureus infection: current clinical opinion and practice.

Although the epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) varies across Europe, healthcare-associated MRSA infections are common in many countries. Despite several national guidelines, the approach to treatment of MRSA infections varies across the continent, and there are multiple areas of management uncertainty for which there is little clinical evidence to guide practice. A faculty, convened to explore some of these areas, devised a survey that was used to compare the perspectives of infection specialists from across Europe on the management of MRSA infections with those of the faculty specialists. The survey instrument, a web-based questionnaire, was sent to 3840 registered delegates of the 19th European Congress of Clinical Microbiology and Infectious Diseases, held in April 2009. Of the 501 (13%) respondents to the survey, 84% were infection/microbiology specialists and 80% were from Europe. This article reports the survey results from European respondents, and shows a broad range of opinion and practice on a variety of issues pertaining to the management of minor and serious MRSA infections, such as pneumonia, bacteraemia, and skin and soft tissue infections. The issues include changing epidemiology, when and when not to treat, choice of treatment, and duration and route of treatment. The survey identified areas where practice can be improved and where further research is needed, and also identified areas of pan-European consensus of opinion that could be applied to European guidelines for the management of MRSA infection.