[Direct identification of bacteria in blood cultures by MALDI-TOF MS].

BACKGROUND: Early and causal administration of antibiotics in patients with a positive blood culture is an essential prerequisite for successful treatment of infection. However, isolation and subsequent identification of bacteria in a blood culture by classical (culture) methods may last several days. MALDI-TOF MS is a method allowing rapid identification of bacteria, not only cultures from culture media, but also directly in clinical specimens. METHODS: The study included samples of positive blood cultures taken from patients in the University Hospital Olomouc between 2016 and 2018 and examined at the Department of Microbiology of the Faculty of Medicine, Palacký University Olomouc. Positive blood culture samples were processed using an in-house method involving the removal of blood cells by low-speed centrifugation. Subsequently, a pellet obtained by high-speed centrifugation and sample washing was tested by MALDI-TOF MS. RESULTS: A total of 110 positive blood cultures were examined using the method of direct identification. At a species level, more Gram-negative bacteria (88 %) than Gram-positive bacteria (79 %) were correctly identified, with higher identification score values being obtained for the former. Identification score values of 2.0 or higher were found in 62 % of blood cultures containing Gram-negative bacteria and 17 % of blood cultures containing Gram-positive bacteria. Identification score values ranging from 1.7 to 2.0 were found in 21 % of Gram-negative blood cultures and 33 % of blood cultures containing Gram-positive bacteria. CONCLUSION: Direct identification of microorganisms from positive blood cultures using MALDI-TOF MS enables more rapid diagnosis. By reducing the time required to obtain the result of pathogen identification, it may positively affect the antibiotic treatment of patients.

Quinolone-resistant Escherichia coli in Poultry Farming.

Increasing bacterial resistance to quinolone antibiotics is apparent in both humans and animals. For humans, a potential source of resistant bacteria may be animals or their products entering the human food chain, for example poultry. Between July 2013 and September 2014, samples were collected and analyzed in the Moravian regions of the Czech Republic to isolate the bacterium Escherichia coli. As a result, 212 E. coli isolates were obtained comprising 126 environmental isolates from poultry houses and 86 isolates from cloacal swabs from market-weight turkeys. Subsequently, the E. coli isolates were tested for susceptibility to selected antibiotics. Resistance of the poultry isolates to quinolones ranged from 53% to 73%. Additionally, the presence of plasmid-mediated resistance genes was studied. The genes were confirmed in 58% of the tested strains. The data on resistance of isolates from poultry were compared with results of resistance tests in human isolates obtained in the same regions. The high levels of resistance determined by both phenotyping and genotyping methods and reported in the present study confirm the fact that the use of fluoroquinolones in poultry should be closely monitored.

Occurrence of bacteria producing broad-spectrum beta-lactamases and qnr genes in hospital and urban wastewater samples.

The aims were to investigate the level of antibiotic-resistant bacteria in hospital and urban wastewater and to determine the similarity of isolates obtained from wastewater and hospitalized patients. Wastewater samples were collected in September 2013 and 2014. After identification using MALDI-TOF MS, beta-lactamase production was determined by relevant phenotypic tests. Genes responsible for the production of single beta-lactamase groups and Qnr proteins were established. The epidemiological relationship of the isolates from wastewater and hospitalized patients was determined by PFGE. A total of 51 isolates of enterobacteria were obtained. Overall, 45.1% of them produced broad-spectrum beta-lactamases. Genes encoding TEM, SHV, CTX-M, CIT, DHA and EBC types of enzymes and Qnr proteins were detected. No broad-spectrum beta-lactamase production was confirmed in the urban wastewater treatment plant. The most important finding was the detection of two identical isolates of K. pneumoniae in 2013, one from a patient's urinary catheter and the other from a wastewater sample.

[The use of MALDI-TOF MS for direct identification of bacteria in clinical specimens].

MALDI-TOF MS is a method enabling rapid identification of bacteria. This is also important for early initiation of adequate antibiotic therapy in patients with infections. In this review, various methods for direct detection of bacteria in clinical specimens are described. The fundamental part deals with direct identification of bacteria from positive blood cultures. Attention is also paid to identification of bacteria from urine and cerebrospinal fluid. Finally, reliability of the methods is mentioned in comparison with conventional methods.

[Prevalence of Salmonella in meat and meat products in Moravia in 2010-2015]. / Výskyt salmonel v mase a masných výrobcích na Morave v letech 2010 az 2015.

OBJECTIVES: Bacteria of the genus Salmonella greatly contribute to foodborne infections of the gastrointestinal tract in humans. An important source of the diseases is foods of animal origin. The study aimed at monitoring and assessing the prevalence of individual Salmonella serovars in samples of meat and meat products collected in Moravia, Czech Republic. MATERIAL AND METHODS: Between 2010 and 2015, the State Veterinary Institute in Olomouc performed microbiology tests in a total of 52,735 meat and meat product samples to detect Salmonella spp. The samples were collected in Moravia and a part of East Bohemia. Bacteriological examination of the samples was carried out in accordance with the Czech version of the European Standard EN ISO 6579 : 2002. Genus identification of suspected isolates was performed using the MALDI-TOF MS method; Salmonella serotypes were identified by a slide agglutination test using the White-Kaufmann-Le Minor scheme. RESULTS: Salmonella spp. were detected in 2.4 % of the 52,735 samples examined. The highest rate of detection (21.9 %) was noted in poultry meat, followed by poultry meat preparations (9.1 % of positive samples) and other meat preparations (0.7 % of positive samples). The serovars most frequently identified from positive samples were Salmonella Infantis and S. Derby. The rates of Salmonella spp. detected in the monitored commodities have been increasing since 2012. However, this may be due to a better risk analysis when selecting samples to be tested. CONCLUSION: Salmonella spp. were most frequently detected in poultry and poultry products. The other types of meat and meat products constituted only a small proportion of the positive cases. The analysis of Salmonella spp. isolated from foods showed that serovars most prevalent in meat and meat products are different from the serovar S. Enteritidis, mainly responsible for causing the diseases in humans.

[Vancomycin-resistant enterococci - the nature of resistance and risk of transmission from animals to humans]. / Problematika vankomycín rezistentných enterokokov - podstata rezistencie a riziko prenosu zo zvierat na cloveka.

Enterococci are part of the normal intestinal flora of humans and animals. Under certain circumstances, they are capable of extraintestinal conversion to opportunistic pathogens. They cause endogenous as well as exogenous community and nosocomial infections. The gastrointestinal tract of mammals provides them with favorable conditions for acquisition and spread of resistance genes, for example to vancomycin (van), from other symbiotic bacteria. Thus, vancomycin-resistant enterococci (VRE) become potential reservoirs and vectors of the van genes. Their occurrence in the population of the Czech Republic was first reported by Kolár et al. in 1997. Some variants of the vanA gene cluster carried on Tn1546 which encode resistance to vancomycin are identical in humans and in animals. It means that animals, especially cattle, poultry and pigs, could be an important reservoir of VRE for humans. Kolár and Bardon detected VRE in animals in the Czech Republic for the first time in 2000. In Europe, the glycopeptide antibiotic avoparcin, used as a growth stimulator, is responsible for selection of VRE strains in animals. Strains of Enterococcus faecium from animals may offer genes of antimicrobial resistance to other enterococci or they can be directly dangerous to human. This is demonstrated by finding isolates of E. faecalis from human patients and from pigs having very similar profiles of resistance and virulence genes. The goal of the paper was to point out the similarity between isolates of human and animal strains of enterococci resistant to vancomycin, and the possibility of their bilateral transfer between humans and animals.

[Prolonged culture in a humid chamber increases the yields of pathogenic bacteria from the respiratory tract samples of patients suffering from cystic fibrosis].

Current standards of care for cystic fibrosis (CF) patients lack unequivocal recommendations concerning the duration of primary culture of bacteriological samples. With the exception of Burkholderia cepacia (5 days), the minimum recommended duration of primary culture varies between 48 and 72 hours. Our aim was to evaluate the effect of an extended 10-day period of primary culture in a humid chamber in samples acquired from the respiratory tract of patients suffering from CF. Compared to standard culture, prolonged culture in a humid chamber yielded 1.85 times more isolates of pathogenic species in pharyngeal swabs (76 versus 41 isolates) and 1.4 times more isolates in sputum samples (116 versus 82), but only 1.14 times more isolates in nasal swabs (25 versus 22). Prolonged culture was most beneficial for Achromobacter spp. (6 versus 0), Stenotrophomonas maltophilia (16 versus 5) and Pseudomonas aeruginosa (69 versus 49), whereas there was little or no benefit at all for Staphylococcus aureus (87 versus 73) and Moraxella catarrhalis (10 versus 10). Therefore, prolonged culture in a humid chamber may definitely be recommended for pharyngeal swabs and sputum samples obtained from patients suffering from CF to achieve the maximum recovery rate of pathogenic bacteria, in particular non-fermenting Gram-negative rods.

[Identification of zoonotic bacterial pathogens by the MALDI TOF MS method]. / Identifikace bakteriálních puvodcu zoonóz metodou MALI TOF MS.

OBJECTIVE: To verify whether the MALDI TOF MS method can be used for rapid identification of selected zoonotic bacterial pathogens isolated from various types of materials in the real conditions of routine laboratory work. MATERIAL AND METHODS: Between August 2010 and April 2015, the Bruker's MALDI TOF MS system was used for 4,174 identifications of selected zoonotic bacterial pathogens (Salmonella spp., Campylobacter jejuni, Campylobacter coli, Listeria monocytogenes, Yersinia enterocolitica, Yersinia pseudotuberculosis, Francisella tularensis, Brucella melitensis, Brucella suis and Cronobacter sakazakii). The samples were prepared for the test by simply mixing a bacterial culture with a matrix on a steel target plate. The results were evaluated with a standard protocol of the system using the MALDI Biotyper software under operating conditions. RESULTS: In 74.8 % of the tested isolates of the above bacterial species, the identification scores ranged between 2 and 3, which is satisfactory for result interpretation in routine practice. Acceleration of identification of Campylobacter spp. and Listeria monocytogenes by testing suspicious cultures obtained directly from selective-diagnostic media decreased the identification scores in these cases. CONCLUSION: MALDI TOF MS is a suitable and rapid method for identification of the selected zoonotic bacterial pathogens.

[Potential use of mass spectrometry for subtyping of Campylobacter]. / Moznosti vyuzití hmotnostrí spektrometrie k subtypizaci kampylobakteru.

OBJECTIVES: Molecular epidemiology is a field that uses results of typing techniques to obtain information on detailed characterization of bacterial strains for determining the identity, similarity or difference in bacteria of the same genus, species or serotype. Nowadays, the most commonly used methods are based on monitoring differences in bacterial genotypes. However, most of these techniques are time-consuming and costly. A method increasingly used in routine microbiological testing is matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS), which is based on analysis of the bacterial proteome. It is mainly used for rapid and accurate classification of bacteria into genera and species. The aims were to assess the potential use of this method for typing of Campylobacter below the species level and to apply these results in epidemiological investigations. MATERIAL AND METHODS: The study comprised 39 strains of Campylobacter jejuni isolated from food (16) and humans (23). Macrorestriction fragment profiling by pulsed-field gel electrophoresis (PFGE) and simultaneous protein profile analysis using MALDI-TOF MS were performed for all tested strains. RESULTS: Similar pulse profiles were found among isolates originating from the same outbreak or repeatedly collected from a single patient. The same pulse profiles were also detected in strains of unknown relationship but sharing the same place of origin and year of isolation. The comparison of dendrograms from both analyses showed that strains identified as identical by PFGE appeared in the same subgroups in dendrograms obtained by MALDI-TOF MS, the only exception being isolates repeatedly collected from a single patient. CONCLUSION: The results suggest that confirmation of the identity or similarity of strains in accordance with the established epidemiological facts has not been clearly demonstrated using MALDI-TOF MS.

[Dogs as a possible source of human Campylobacter infecfions]. / Psi jako mozný zdroj jampylobakterových infekcí cloveka.

OBJECTIVES: The aims of this study were to obtain current information on the prevalence and species representation of bacteria of the genus Campylobacter in dogs in Moravia and to evaluate the risk factors affecting their occurrence with respect to possible transmission to the human population. MATERIAL AND METHODS: Rectal swabs of dogs obtained in the routine practice of veterinarians in the South Moravian and Olomouc -regions were examined from May 2013 to December 2014. The basic tests were performed in laboratories of the State Veterinary Institute in Olomouc and the University of Veterinary and Pharmaceutical Sciences Brno. To detect Campylobacter spp., the samples were cultured on mCCDA (modified charcoal-cefoperazone-deoxycholate agar). Suspected colonies were confirmed by MALDI-TOF MS (Biotyper Microflex, Bruker) or using specific PCR which allows to distinguish between the species C. jejuni, C. coli, C. lari and C. upsaliensis. A detailed history was obtained from questionnaires completed by the dog owners. RESULTS: From a total of 258 rectal swabs examined, 41 samples were positive (16 %). The most frequently detected species was C. jejuni, followed by C. upsaliensis a C. coli. There was only one sample of C. lari. The evaluation of the questionnaire data showed that the frequency of Campylobacter spp. and their species representation depended on the age of the animals, the composition of feed and the clinical signs of the disease. CONCLUSION: Young dogs on a homemade diet and with diarrhea may be considered a risk group in terms of possible transmission of Campylobacter infections from pets to humans. Households with young children are the most affected group in the Czech Republic and EU countries. As such, they should be given a high priority with respect to the basic hygiene rules if they breed dogs, especially puppies.

Vancomycin-resistant enterococci in rooks (Corvus frugilegus) wintering throughout Europe.

This study's aims were to assess the prevalence of, and to characterize, vancomycin-resistant enterococci (VRE) from rooks (Corvus frugilegus) wintering in Europe during 2010/2011. Faeces samples were cultivated selectively for VRE and characterized. Pulsed-field gel electrophoresis and multilocus sequence typing (MLST) were used to examine epidemiologic relationships of vanA-containing VRE. The vanA-carrying VRE were tested in vitro for mobility of vancomycin resistance traits. VRE were found in 62 (6%) of 1073 rook samples. Enterococcal species diversity comprised Enterococcus gallinarum (48 isolates), followed by E. faecium (9) and E. faecalis (5). Eight VRE harboured the vanA and ermB genes. Seven vanA-carrying VRE originated from the Czech Republic and one from Germany. All vanA-carrying VRE were identified as E. faecium. Based on MLST analysis, six vanA-positive isolates were grouped as ST92 type, one isolate belonged to ST121, and the remaining one was described as a novel type ST671. Seven out of eight isolates were able to transfer the vancomycin resistance trait via filter mating with a transfer rate of 8.95 ± 3.25 × 10(-7) transconjugants per donor. In conclusion, wintering rooks in some European countries may disseminate clinically important enterococci and pose a risk for environmental contamination.

[Anisakiasis - a little-known parasitic zoonosis]. / Anisakoza- malo znama parazitarni zoonza.

Parasites of the family Anisakidae cause enteric parasitic zoonoses developing after consumption of inadequately cooked marine fish. Cases of such diseases are reported mainly from Japan or other countries where raw or uncooked fish are traditionally consumed. The presented short communication briefly reports detection of larvae of Pseudoterranova spp., parasites of the family Anisakidae, in a fresh chilled angler-fish (Lophius piscatorius) bought at a retail store in the Czech Republic.

Plasmid-mediated colistin resistance from fresh meat and slaughtered animals in the Czech Republic: nation-wide surveillance 2020-2021.

The aim of this study was to determine the occurrence of plasmid-mediated colistin resistance in domestic and imported meat and slaughter animals in the Czech Republic during 2020-2021 by using selective cultivation and direct PCR testing. A total of 111 colistin-resistant Escherichia coli isolates with mcr-1 gene were obtained from 65 (9.9%, n = 659) samples and subjected to whole-genome sequencing. Isolates with mcr were frequently found in fresh meat from domestic production (14.2%) as well as from import (28.8%). The mcr-1-positive E. coli isolates predominantly originated from meat samples (16.6%), mainly poultry (27.1%), and only minor part of the isolates came from the cecum (1.7%). In contrast to selective cultivation, 205 (31.1%) samples of whole-community DNA were positive for at least one mcr variant, and other genes besides mcr-1 were detected. Analysis of whole-genome data of sequenced E. coli isolates revealed diverse sequence types (STs) including pathogenic lineages and dominance of ST1011 (15.6%) and ST162 (12.8%). Most isolates showed multidrug-resistant profile, and 9% of isolates produced clinically important beta-lactamases. The mcr-1 gene was predominantly located on one of three conjugative plasmids of IncX4 (83.5%), IncI2 (7.3%), and IncHI2 (7.3%) groups. Seventy-two percent isolates of several STs carried ColV plasmids. The study revealed high prevalence of mcr genes in fresh meat of slaughter animals. Our results confirmed previous assumptions that the livestock, especially poultry production, is an important source of colistin-resistant E. coli with the potential of transfer to humans via the food chain. IMPORTANCE We present the first data on nation-wide surveillance of plasmid-mediated colistin resistance in the Czech Republic. High occurrence of plasmid-mediated colistin resistance was found in meat samples, especially in poultry from both domestic production and import, while the presence of mcr genes was lower in the gut of slaughter animals. In contrast to culture-based approach, testing of whole-community DNA showed higher prevalence of mcr and presence of various mcr variants. Our results support the importance of combining cultivation methods with direct culture-independent techniques and highlight the need for harmonized surveillance of plasmid-mediated colistin resistance. Our study confirmed the importance of livestock as a major reservoir of plasmid-mediated colistin resistance and pointed out the risks of poultry meat for the transmission of mcr genes toward humans. We identified several mcr-associated prevalent STs, especially ST1011, which should be monitored further as they represent zoonotic bacteria circulating between different environments.

[Animal sources of Clostridium difficile]. / K problematice animálních zdroju Clostridium difficile.

The bacterium Clostridium difficile is pathogenic for both humans and animals. This feared nosocomial infectious agent is increasingly more important in the community as well. Like in humans, the gastrointestinal tract is infected in animals. The bacterium may be transmitted from animals to humans via the food chain (e.g. pork meat) or by direct contact. Identical human and animal isolates of C. difficile have been reported in several studies. The article presents results from a small local study aimed at detecting C. difficile and its toxins in the District of Olomouc, Czech Republic, by 3 different methods.

Deep brain stimulation electrode position impact on parkinsonian non-motor symptoms.

BACKGROUND: In this study we evaluated the impact of location of deep brain stimulation electrode active contact in different parts of the subthalamic nucleus on improvement of non-motor symptoms in patients with Parkinson's disease. METHODS: The subthalamic nucleus was divided into two (dorsolateral/ventromedial) and three (dorsolateral, medial, ventromedial) parts. 37 deep brain stimulation electrodes were divided according to their active contact location. Correlation between change in non-motor symptoms before and one and four months after deep brain stimulation electrode implantation and the location of active contact was made. RESULTS: In dividing the subthalamic nucleus into three parts, no electrode active contact was placed ventromedially, 28 active contacts were located in the medial part and 9 contacts were placed dorsolaterally. After one and four months, no significant difference was found between medial and dorsolateral positions. In the division of the subthalamic nucleus into two parts, 13 contacts were located in the ventromedial part and 24 contacts were placed in the dorsolateral part. After one month, significantly greater improvement in the Non-motor Symptoms Scale for Parkinson's disease (P=0.045) was found on dorsolateral left-sided stimulation, but no significant differences between the ventromedial and dorsolateral positions were found on the right side. CONCLUSION: This study demonstrated the relationship between improvement of non-motor symptoms and the side (hemisphere, left/right) of the deep brain stimulation electrode active contact, rather than its precise location within specific parts of the subthalamic nucleus in patients treated for advanced Parkinson's disease.

[Direct detection of the brucellosis-causing pathogen--a case report]. / Primý prukaz puvodce maltské horecky--kazuistika.

Bacterial zoonoses still represent a serious medical problem. One of the less frequent but severe zoonoses is brucellosis caused by the bacterium Brucella melitensis. The presented case report describes relapsing imported brucellosis in a young male. In addition to four serological tests, the diagnosis was confirmed by direct detection of the pathogen in blood culture. The isolate of Brucella melitensis was identified using the MALDI-TOF BioTyper method and subsequently also by PCR.

Wild boar as a potential reservoir of zoonotic tick-borne pathogens.

The wild boar (Sus scrofa) population has increased dramatically over the last decades throughout Europe and it has become a serious pest. In addition, the common habitat of wild boar and of the tick, Ixodes ricinus, indicates the potential of wild boar to play a role in epidemiology of epizootic and zoonotic tick-borne pathogens, including Anaplasma phagocytophilum. In Europe, epidemiological cycles and reservoirs of A. phagocytophilum, including its zoonotic haplotypes, are poorly understood. In this study, we focused on detection and further genetic characterization of A. phagocytophilum and piroplasmids in 550 wild boars from eleven districts of Moravia and Silesia in the Czech Republic. Using highly sensitive nested PCR targeting the groEL gene, the DNA of A. phagocytophilum was detected in 28 wild boars (5.1 %) representing six unique haplotypes. The dominant haplotype was found in 21 samples from 7 different districts. All detected haplotypes clustered in the largest clade representing the European ecotype I and the dominant haplotype fell to the subclade with the European human cases and strains from dogs and horses. Nested PCR targeting the variable region of the 18S rRNA gene of piroplasmids resulted in one positive sample with 99.8 % sequence identity to Babesia divergens. The presence of these two pathogens that are primarily circulated by I. ricinus confirms the local participation of wild boar in the host spectrum of this tick and warrants experimental studies to address wild boar as a reservoir of zoonotic haplotypes of A. phagocytophilum.

Prevalence of Vancomycin-Resistant Enterococci and Antimicrobial Residues in Wastewater and Surface Water.

Due to the extensive use of antimicrobial agents in human and veterinary medicine, residues of various antimicrobials get into wastewater and, subsequently, surface water. On the one hand, a combination of processes in wastewater treatment plants aims to eliminate chemical and biological pollutants; on the other hand, this environment may create conditions suitable for the horizontal transfer of resistance genes and potential selection of antibiotic-resistant bacteria. Wastewater and surface water samples (Morava River) were analyzed to determine the concentrations of 10 antibiotics and identify those exceeding so-called predicted no-effect environmental concentrations (PNECs). This study revealed that residues of five of the tested antimicrobials, namely ampicillin, clindamycin, tetracycline, tigecycline and vancomycin, in wastewater samples exceeded the PNEC. Vancomycin concentrations were analyzed with respect to the detected strains of vancomycin-resistant enterococci (VRE), in which the presence of resistance genes, virulence factors and potential relationship were analyzed. VRE were detected in 16 wastewater samples (11%) and two surface water samples (6%). The PNEC of vancomycin was exceed in 16% of the samples. Since the detected VRE did not correlate with the vancomycin concentrations, no direct relationship was confirmed between the residues of this antimicrobials and the presence of the resistant strains.

Analysis of Vancomycin-Resistant Enterococci in Hemato-Oncological Patients.

Enterococci are important bacterial pathogens, and their significance is even greater in the case of vancomycin-resistant enterococci (VRE). The study analyzed the presence of VRE in the gastrointestinal tract (GIT) of hemato-oncological patients. Active screening using selective agars yielded VRE for phenotypic and genotypic analyses. Isolated strains were identified with MALDI-TOF MS, (Matrix-Assisted Laser Desorption/Ionization Time-of-Flight Mass Spectrometry) their susceptibility to antibiotics was tested, and resistance genes (vanA, vanB, vanC-1, vanC2-C3) and genes encoding virulence factors (asa1, gelE, cylA, esp, hyl) were detected. Pulsed-field gel electrophoresis was used to assess the relationship of the isolated strains. Over a period of three years, 103 VanA-type VRE were identified in 1405 hemato-oncological patients. The most frequently detected virulence factor was extracellular surface protein (84%), followed by hyaluronidase (40%). Unique restriction profiles were observed in 33% of strains; clonality was detected in 67% of isolates. The study found that 7% of hemato-oncological patients carried VRE in their GIT. In all cases, the species identified was Enterococcus faecium. No clone persisted for the entire 3-year study period. However, genetically different clusters were observed for shorter periods of time, no longer than eight months, with identical VRE spreading among patients.

O-Arm Navigated Frameless and Fiducial-Less Deep Brain Stimulation.

OBJECT: Deep brain stimulation (DBS) is a very useful procedure for the treatment of idiopathic Parkinson's disease (PD), essential tremor, and dystonia. The authors evaluated the accuracy of the new method used in their center for the placing of DBS electrodes. Electrodes are placed using the intraoperative O-arm™ (Medtronic)-controlled frameless and fiducial-less system, Nexframe™ (Medtronic). Accuracy was evaluated prospectively in eleven consecutive PD patients (22 electrodes). METHODS: Eleven adult patients with PD were implanted using the Nexframe system without fiducials and with the intraoperative O-arm (Medtronic) system and StealthStation™ S8 navigation (Medtronic). The implantation of DBS leads was performed using multiple-cell microelectrode recording, and intraoperative test stimulation to determine thresholds for stimulation-induced adverse effects. The accuracy was checked in three different steps: (1) using the intraoperative O-arm image and its fusion with preoperative planning, (2) using multiple-cell microelectrode recording and counting the number of microelectrodes with the signal of the subthalamic nucleus (STN) and finally, (3) total error was calculated according to a postoperative CT control image fused to preoperative planning. RESULTS: The total error of the procedure was 1.79 mm; the radial error and the vector error were 171 mm and 163 mm. CONCLUSIONS: Implantation of DBS electrodes using an O-arm navigated frameless and fiducial-less system is a very useful and technically feasible procedure with excellent patient toleration with experienced Nexframe users. The accuracy of the method was confirmed at all three steps, and it is comparable to other published results.