Prevalence and molecular epidemiology of Staphylococcus aureus nasal colonization in four nursing home residents in Crete, Greece.

Nursing homes are considered as reservoirs for methicillin-resistant Staphylococcus aureus (MRSA). The present study investigated the point prevalence and molecular epidemiology of S. aureus colonization among nursing home residents. The study population comprised of 227 residents, living in four nursing homes of the Heraklion, Crete, Greece area, between January and December 2015. From each nursing home, swabs from the anterior nares of all eligible participants were obtained within a 2-week period. The isolated S. aureus strains were identified and screened by standard microbiological and molecular epidemiological methods. S. aureus carriage was found in 62 out of 227 participants (38.4%) with 33 out of 62 (53.2%) being MRSA. The median age was 83 years (range 52-103). Females were more frequently colonized [47 (75.8%)]. All 33 methicillin resistant Staphylococcus aureus (MRSA) isolates were mecA-positive carrying SCCmec type IV, 30 (91%) the fnbA, and 17 (51.5%) the PVL genes. Thirty-two (97%) belonged to a single pulsotype C; among them, the PVL-positives belonged to ST80 clone, whereas, the PVL-negatives to ST225. Among the 33 MRSA isolates, 32 (97%) were clindamycin-resistant, carrying the ermA gene. Methicillin-susceptible Staphylococcus aureus (MSSA) strains showed polyclonality and 76% were PVL-positive. In conclusion the present study has shown that nursing homes in our area can be regarded as important reservoirs for community-associated MRSA (CA-MRSA).

The burden on public emergency departments during the economic crisis years in Greece: a two-center comparative study.

OBJECTIVES: The effects of the Greek economic crisis on the emergency departments (EDs) of public hospitals have not been evaluated. The study aims to evaluate the burden of the financial crisis on public hospital's EDs. STUDY DESIGN: The present study is a retrospective two-center comparative study. METHODS: ED visits, related admissions per year, and the admissions/visits ratio at two public Greek hospitals, the Sismanogleio of Athens (SHA) and the University Hospital of Crete (UHC), from 2008 to 2016 were retrospectively studied. A linear model was fitted for each variable, and the slope values of the linear equations were calculated and compared between the two institutions. RESULTS: ED visits of the UHC exhibited 8.9% increase during the study period, whereas related admissions and admissions/visits ratio increased by 23.4% and 12.5%, respectively. ED visits at the SHA exhibited 5.4% increase, whereas related admissions showed 6% decrease and the admissions/visits ratio was decreased by 8%. Significant differences between the rates of admissions (P < 0.001) and admissions/visits ratio (P = 0.001) among the two hospitals were observed. CONCLUSIONS: Both institutions showed similarly increased ED visits. However, the UHC serving mainly rural, but also suburban and urban population, exhibited different changes regarding admissions and admissions/visits ratio compared with the SHA serving mainly an urban and suburban one, reflecting the way the crisis affected each social group. Depression has amplified the Greek National Health System structural problems and exposed the problematic urban primary health care. Improvement of primary urban health care, autonomy of EDs, and establishment of emergency medicine as independent specialty in Greece could serve better patients seeking care in public hospitals' EDs.

Multidrug-resistant Gram-negative osteomyelitis: a 10-year study.

AIM: Few series of osteomyelitis due to multi-drug (MDR) or extensively-drug resistant (XDR) gram-negative bacteria exist. A retrospective study of MDR and XDR gram-negative osteomyelitis cases was performed, aiming to investigate causative organisms, proper surgical and medical management, as well as outcome. PATIENTS AND METHODS: All patients, treated at the University hospital of Crete between 2007 and 2016 for acute osteomyelitis, due to MDR or XDR gram-negative pathogens were evaluated. RESULTS: A total of 14 patients (8 males) were identified with a mean age of 50.6 years. Five Acinetobacter baumanii cases, 3 XDR and 2 MDR, were found. Furthermore, 3 MDR Klebsiella pneumoniae and 3 MDR Enterobacter cloacae isolates were identified. Additionally, 2 MDR Escherichia coli, as well as 2 Pseudomonas aeruginosa, 1 XDR and 1 MDR, were isolated. One case of Roseomonas gilardii was also identified. In 5 cases the same pathogen was also isolated from blood. Five out of the 14 patients were smokers, 6 were suffering severe injury, 4 had diabetes-mellitus, 2 chronic renal disease and 2 were obese. Most causative organisms had hospital origin. All patients received first line empirical combination antimicrobial treatment, proven effective in 4. Thirteen patients were also subjected to surgical treatment. The study included mainly young individuals, most likely due to the high incidence of traffic accidents involving young adults in Crete. CONCLUSIONS: Antimicrobial regimens are important supplements to surgical treatment of acute osteomyelitis. However, due to emergence of resistant microorganisms, compliance with strict rules of antimicrobial strategy is of utmost importance.

Clostridium difficile in Crete, Greece: epidemiology, microbiology and clinical disease.

We studied the epidemiology and microbiology of Clostridium difficile and the characteristics of patients with C. difficile infection (CDI) in Crete in three groups of hospitalized patients with diarrhoea: group 1 [positive culture and positive toxin by enzyme immunoassay (EIA)]; group 2 (positive culture, negative toxin); group 3 (negative culture, negative toxin). Patients in group 1 were designated as those with definitive CDI (20 patients for whom data was available) and matched with cases in group 2 (40 patients) and group 3 (40 patients). C. difficile grew from 6% (263/4379) of stool specimens; 14·4% of these had positive EIA, of which 3% were resistant to metronidazole. Three isolates had decreased vancomycin susceptibility. Patients in groups 1 and 2 received more antibiotics (P = 0·03) and had more infectious episodes (P = 0·03) than patients in group 3 prior to diarrhoea. Antibiotic administration for C. difficile did not differ between groups 1 and 2. Mortality was similar in all three groups (10%, 12·5% and 5%, P = 0·49). CDI frequency was low in the University Hospital of Crete and isolates were susceptible to metronidazole and vancomycin.

Trends of isolation of intrinsically resistant to colistin Enterobacteriaceae and association with colistin use in a tertiary hospital.

The objective of this investigation was to evaluate the association between colistin consumption and the isolation of intrinsically resistant to colistin Enterobacteriaceae (IRCE) in a university hospital in Crete, Greece. The database of the microbiological laboratory was reviewed retrospectively during 2006-2010. All positive cultures for IRCE were retrieved. We assessed the total consumption of colistin in medical, surgical, and intensive care units (ICUs). A total of 1,304 single-patient IRCE isolates were recorded. Of these, 466 (35.7%) were hospital-acquired, while 838 (64.3%) were community-acquired. Proteus spp. accounted for 72% of them, Serratia spp. for 16.6%, Morganella morganii for 8.4%, and Providencia spp. for 3%. Urine (44.8%), pus (20.4%), and lower respiratory tract specimens (12.8%) accounted for the majority of specimens. IRCE isolated during the first half (2006 to 1st semester of 2008) and second half (2nd semester of 2008 to 2010) of the study period accounted for 5.8% and 7.4% of Gram-negative isolates, respectively (p < 0.001). Colistin consumption was not different in the two periods in the hospital, but in the ICU, it was higher in the second half of the study period (p = 0.013). Colistin consumption was associated with the isolation of hospital-acquired IRCE (p = 0.037); a trend was noted between colistin consumption and the isolation of IRCE in the ICU (p = 0.057). In this study, colistin consumption was associated with the isolation of hospital-acquired IRCE. The use of colistin increased in the ICU during the study period. Prudent use of colistin is essential for the prevention of nosocomial outbreaks due to resistant IRCE.

Characteristics, risk factors and outcomes of adult cancer patients with extensively drug-resistant Pseudomonas aeruginosa infections.

OBJECTIVE: To evaluate the characteristics and outcomes of cancer patients with extensively drug-resistant (XDR) Pseudomonas aeruginosa infections. METHODS: This was a retrospective cohort of P. aeruginosa infections in cancer patients in Crete, Greece. Patients were followed until discharge. Mortality, predictors of mortality and risk factors for XDR P. aeruginosa infection were studied. RESULTS: Ninety seven episodes (89 patients) of P. aeruginosa infections (52 with bacteremia) were included in the study. In 22 cases, the infection was due to XDR isolates. All XDR isolates were susceptible to colistin and variably resistant to almost all other antibiotics. The multivariate analysis showed that the independent risk factors for XDR P. aeruginosa infection were hematologic malignancy (OR 40.7, 95 % CI 4.5-367.6) and prior fluoroquinolone use (OR 11.0, 95 % CI 2.0-60.5); lymphopenia was inversely associated with XDR infections (OR 0.16, 95 % CI 0.03-0.92). Mortality was 43 %; infection-related mortality was 24 %. Bacteremia (OR 8.47, 95 % CI 2.38-30.15), infection due to XDR isolates (OR 5.11, 95 % CI 1.15-22.62) and age (OR 1.05, 95 % CI 1.00-1.09) were independently associated with mortality. CONCLUSION: Mortality in cancer patients with P. aeruginosa infections was high. Infection due to XDR isolates was independently associated with mortality.

Antimicrobial activity of prulifloxacin in comparison with other fluoroquinolones against community-acquired urinary and respiratory pathogens isolated in Greece.

Prulifloxacin, the prodrug of ulifloxacin, is a broad-spectrum fluoroquinolone rather recently introduced in certain European countries. We compared the antimicrobial potency of ulifloxacin with that of other fluoroquinolones against common urinary and respiratory bacterial pathogens. The microbial isolates were prospectively collected between January 2007 and May 2008 from patients with community-acquired infections in Greece. Minimum inhibitory concentrations (MICs) were determined for ciprofloxacin, levofloxacin, moxifloxacin (for respiratory isolates only), and ulifloxacin using the E-test method. The binary logarithms of the MICs [log2(MICs)] were compared by using the Wilcoxon signed-ranks test. A total of 409 isolates were studied. Ulifloxacin had the lowest geometric mean MIC for the 161 Escherichia coli, 59 Proteus mirabilis, and 22 Staphylococcus saprophyticus urinary isolates, the second lowest geometric mean MIC for the 38 Streptococcus pyogenes respiratory isolates (after moxifloxacin), and the third lowest geometric mean MIC for the 114 Haemophilus influenzae and the 15 Moraxella catarrhalis respiratory isolates (after ciprofloxacin and moxifloxacin). Compared with levofloxacin, ulifloxacin had lower log2(MICs) against E. coli (p < 0.001), P. mirabilis (p < 0.001), S. saprophyticus (p < 0.001), and S. pyogenes (p < 0.001). Compared with ciprofloxacin, ulifloxacin had lower log2(MICs) against P. mirabilis (p < 0.001), S. saprophyticus (p = 0.008), and S. pyogenes (p < 0.001), but higher log2(MICs) against H. influenzae (p < 0.001) and M. catarrhalis (p = 0.001). In comparison with other clinically relevant fluoroquinolones, ulifloxacin had the most potent antimicrobial activity against the community-acquired urinary isolates studied and very good activity against the respiratory isolates.

Long-term trends in the epidemiology and resistance of childhood bacterial enteropathogens in Crete.

In this study, we investigated the long-term trends in the epidemiology and susceptibility of bacterial enteropathogens among children in a well-defined area of adequate health standards. The study included all children younger than 14 years of age treated for enteritis at Heraklion University General Hospital on the island of Crete during the 18-year period from January 1993 to December 2010. Stool specimens were tested for Salmonella, Shigella, Campylobacter, enteropathogenic Escherichia coli (EPEC), Yersinia, and Aeromonas species. Of the 33,032 stool samples from patients of any age, 2,912 (8.82%) were positive for bacterial enteropathogens. The 1,597 isolates from children were identified as S. enterica (42.3%), Campylobacter spp. (33.6%), EPEC (17.4%), Y. enterocolitica (5.82%), A. hydrophila (0.44%), and Shigella spp. (0.38%). A decline in prevalence was observed for all bacterial enteropathogens. Taken as a total, enteropathogens were susceptible to gentamicin, ceftriaxone, ciprofloxacin, co-trimoxazole, and amoxicillin in 98.8%, 88.0%, 83.0%, 67.1%, and 59.6%, respectively. During the study period, the susceptibility rates decreased for co-trimoxazole (p<0.0001) and ciprofloxacin (p<0.001), and increased for amoxicillin (p<0.0001). Our findings suggest declining long-term trends in the prevalence of bacterial enteropathogens and changes in susceptibility rates to first-line antibacterial agents. These changing trends in the long-term morbidity and susceptibility call for ongoing surveillance and tailored management.

Antimicrobial susceptibility of non-fermenting Gram-negative isolates to isepamicin in a region with high antibiotic resistance.

The alarmingly increasing resistance rates among non-fermenting Gram-negative species, particularly Pseudomonas aeruginosa and Acinetobacter baumannii, intensified the interest in alternative antibiotic treatment options. Isepamicin, an old aminoglycoside, may play a role in the treatment of patients with infections caused by those multi-drug resistant pathogens. We evaluated the antimicrobial activity of isepamicin against non-fermenting Gram-negative isolates collected of the microbiological laboratory at the University Hospital of Heraklion, Crete, Greece from 2004 to the first trimester of 2011. We tested a total of 4,219 isolates (66.2 % Pseudomonas spp., 30 % Acinetobacter spp., 3.8 % other non-fermenters). The lower respiratory tract, pus, and urine were the most frequent sites of isolation (29.7 %, 19.9 %, and 12.9 %, respectively). Overall, 2768 (65.6 %) of the evaluated isolates were susceptible to isepamicin (including 79.9 % of Pseudomonas spp, 37.2 % of Acinetobacter spp, 43.1 % of other non-fermenters). Isepamicin exhibited higher antimicrobial activity compared to broad spectrum penicillins, cephalosporins, other aminoglycosides, carbapenems, and fluoroquinolones. Only colistin was more active than isepamicin. Additionally, 41.7 % of carbapenem-resistant and 53.2 % of colistin-resistant P. aeruginosa isolates were susceptible to isepamicin. The susceptibility rates for the respective types of A. baumannii isolates were 12 % and 6.2 %. Yet, isepamicin was active against 29.2 % of A. baumannii that were resistant to all other tested aminoglycosides. Isepamicin exhibits considerable antimicrobial activity against Gram-negative non-fermenters in a region with high antimicrobial resistance. Particularly, isepamicin may provide a therapeutic option for infections from carbapenem- and colistin-resistant P. aeruginosa and other aminoglycoside-resistant A. baumannii. Further modifications in the aminoglycoside molecule may provide formulations with enhanced antimicrobial activity.

Synergy of fosfomycin with carbapenems, colistin, netilmicin, and tigecycline against multidrug-resistant Klebsiella pneumoniae, Escherichia coli, and Pseudomonas aeruginosa clinical isolates.

Fosfomycin represents a potential last-resort treatment option for infections with certain multidrug-resistant (MDR) Gram-negative pathogens. We evaluated double-drug combinations of fosfomycin with imipenem, meropenem, doripenem, colistin, netilmicin, and tigecycline for in vitro synergy against 100 MDR Klebsiella pneumoniae, Escherichia coli, and Pseudomonas aeruginosa clinical isolates, using the Etest method. Synergy was defined as a fractional inhibitory concentration index ≤ 0.5. The isolates were consecutively collected at a university hospital in Greece from various clinical specimens. Against 50 serine carbapenemase-producing K. pneumoniae isolates, synergy of fosfomycin with imipenem, meropenem, doripenem, colistin, netilmicin, and tigecycline was observed for 74.0%, 70.0%, 74.0%, 36.0%, 42.0%, and 30.0% of the isolates, respectively. Against 14 extended-spectrum ß-lactamase (ESBL)-producing K. pneumoniae isolates, synergy of fosfomycin with imipenem, meropenem, doripenem, colistin, netilmicin, and tigecycline was observed for 78.6%, 42.9%, 42.9%, 7.1%, 42.9%, and 21.4%, respectively; for 20 ESBL-producing E. coli isolates, the corresponding values were 55.0%, 25.0%, 30.0%, 15.0%, 25.0%, and 25.0%; and for 15 MDR P. aeruginosa isolates, the corresponding values were 46.7%, 53.3%, 73.3%, 13.3% , 13.3%, and 13.3%. Antagonism was not observed for any of the combinations tested. Further studies are needed in order to confirm the clinical relevance of the above findings.

Multi-drug-resistant gram-negative bacterial infection in surgical patients hospitalized in the ICU: a cohort study.

We sought to identify risk factors for postoperative infections, caused by multi-drug-resistant gram-negative bacteria (MDR-GNB) in surgical patients. This was a retrospective cohort study among patients hospitalized in the intensive care unit (ICU) for more than 5 days, following general surgical operations. Comparison of patients who developed infection caused by MDR-GNB with the remainder of the cohort showed that every minute of operative time, use of special treatments during hospitalization (antineoplastic, immunosuppressive or immunomodulating therapies), every day of metronidazole, and every day of carbapenems use, increased patients' odds to acquire an infection caused by MDR-GNB by 0.7%, 8.9 times, 9%, and 9%, respectively [OR (95% CI): 1.007 (1.003-1.011), p = 0.001; 8.9 (1.8-17.3), p = 0.004; 1.09 (1.04-1.18), p = 0.039; 1.09 (1.01-1.18), p = 0.023, respectively]. The above were adjusted in the multivariable analysis for the confounder of time distribution of infections caused by MDR-GNB. Finally, the secondary comparison, with patients that did not develop any infection, showed that patients who had received antibiotics, within 3 months prior to admission, had 3.8 times higher odds to acquire an infection caused by MDR-GNB [OR (95% CI): 3.8 (1.07-13.2), p = 0.002]. This study depicts certain, potentially modifiable, risk factors for postoperative infections in patients hospitalized in the ICU for more than 5 days.

Empirical therapy with ceftazidime combined with levofloxacin or once-daily amikacin for febrile neutropenia in patients with neoplasia: a prospective comparative study.

Combination antimicrobial therapy represents common practice in the treatment of febrile neutropenia aiming to broaden the antimicrobial spectrum against Gram-negative pathogens. We did a prospective, non-randomized, comparative study to evaluate ceftazidime plus either levofloxacin or once-daily amikacin as empirical regimens for febrile neutropenia in patients with solid tumor or hematopoietic neoplasm in a region of high baseline resistance prevalence. We included 285 febrile neutropenic episodes in 235 individual patients. One hundred forty-eight cases received levofloxacin and 137 received amikacin, both in combination with ceftazidime. More cases in the levofloxacin than the amikacin group had underlying hematological malignancy; most other characteristics of the two groups were well balanced. Nephrotoxicity requiring treatment discontinuation occurred in one case in the amikacin group. No difference in clinical success (79.7% vs. 80.3%, p>0.99) or all-cause mortality (12.8% vs. 11.7%, p=0.86) was noted between the levofloxacin and the amikacin groups, even after adjustment for the independent predictor variables for each endpoint. Sepsis at presentation, presence of localizing symptoms/signs of infection, and isolation of a non-susceptible Gram-negative pathogen independently predicted both clinical success and all-cause mortality. Additionally, underlying solid tumor independently predicted clinical success, while poor prognosis of the underlying neoplasia and skin/soft tissue infection independently predicted mortality. Ceftazidime plus levofloxacin had similar effectiveness to ceftazidime plus amikacin as empirical regimens for febrile neutropenia. Nephrotoxicity with once-daily amikacin was minimal. Inappropriate empirical therapy was associated with worse prognosis.

Infant colonization by Staphylococcus aureus: role of maternal carriage.

Infant colonization by Staphylococcus aureus has not been adequately investigated. In this study, we aimed to define determinants associated with the carriage of S. aureus in early infancy. Serial nasal swabs were collected from 128 infants and their mothers at months 0, 6, and 12 postpartum. S. aureus isolates were characterized by pulsed-field gel electrophoresis (PFGE), multilocus sequence typing (MLST), spa typing, and the presence of chromosomal mecA and of Panton-Valentine leukocidin (PVL) genes. S. aureus was isolated in 17.7% and 15.7% of swabs from infants and mothers, respectively. Carriage rates were higher in infants with carrier mothers, non-smoking mothers, and many siblings. Persistent carriage rates were higher in infants with carrier or non-smoking mothers. S. aureus typing revealed identical strains in 10/15 investigated infant-mother pairs. Among 19 investigated S. aureus isolates from infants, ten harbored mecA and two harbored PVL genes, and these determinants were concomitantly present in isolates from mothers. Resistance to methicillin was 43.6% among all isolates from infants. In conclusion, isolates from infants were commonly identical to isolates from their mothers, pointing to a principal role of maternal carriage in S. aureus colonization in infants.

Serratia infections in a general hospital: characteristics and outcomes.

We aimed to present our experience regarding infections caused by Serratia spp. in a region with relatively high antimicrobial resistance rates. We retrospectively reviewed the databases of the microbiological laboratory of the University Hospital of Heraklion, Crete (2/2004-12/2009). A total of 77 patients [67.5% men, mean age ± standard deviation (SD) = 56.9 ± 24.5 years) were identified; 37.7% were outpatients. Sixty-five (84.4%) of the 77 included patients had a Serratia marcescens isolate; the remaining 12 patients had a non-marcescens Serratia spp. The most frequently observed infections were respiratory tract infection (32.5%) and keratitis/endophthalmitis (20.8%). Seventy-three (94.9%) patients were cured. Four deaths were observed; three of them were considered as attributed to the Serratia infection. No difference was found regarding the characteristics and outcomes between patients with Serratia marcescens and non-marcescens infections. In addition, antipseudomonal penicillins and their combinations with beta-lactamase inhibitors, as well as carbapenemes, and fluoroquinolones exhibited high antimicrobial activity against both the tested Serratia marcescens and non-marcescens isolates. Our study adds useful information regarding the characteristics and outcomes of patients with Serratia infection, as well as the susceptibilities of the respective Serratia marcescens and non-marcescens isolates, in a region with relatively high levels of antimicrobial resistance.

Effects of levofloxacin, moxifloxacin and prulifloxacin on murine gut colonization by Candida albicans.

Fluoroquinolones are broad-spectrum antibiotics increasingly utilized as empirical or prophylactic therapy in the management of cancer patients. We evaluated the effects of newer generation fluoroquinolones on the level of gastrointestinal (GI) colonization by Candida albicans in a previously established mouse model. Adult male Crl:CD1 (ICR) BR mice were fed chow containing Candida albicans or regular chow. The mice fed the Candida chow had their gut colonized by the yeast. Both groups were subsequently given levofloxacin, moxifloxacin, prulifloxacin or normal saline for 10 days. Stool cultures were performed immediately before, at the end, and one week after discontinuation of treatment to determine the level of intestinal yeast colonization. Candida-colonized mice treated with fluoroquinolones had substantially higher yeast counts in their stools than control mice fed Candida containing chow but treated with saline. Mice fed regular chow and treated with the study antibiotics or saline did not have any Candida in their stools. Dissemination of Candida to internal organs was not observed in any animal. In conclusion, we have shown that all fluoroquinolones tested induced substantial increases in the murine intestinal concentration of C. albicans.

Saccharomyces boulardii and Candida albicans experimental colonization of the murine gut.

Saccharomyces boulardii has been and continues to be extensively used as a probiotic, with only rare associations with fungemia. This study evaluated the virulence of this yeast when given as a probiotic, and its role in preventing gastrointestinal (GI) colonization by Candida. Adult male Crl:CD1 (ICR) BR mice were given S. boulardii orally in three different doses or normal saline for 14 days. Stool cultures were performed at the time of discontinuation of yeast administration, as well as 1 and 2 weeks later. Gut colonization was proportional to the given dose but lasted only 1 week and no dissemination of the yeast was detected. S. boulardii was also given for 2 and 4 weeks to mice fed chow containing Candida albicans. S. boulardii in the gut did not affect Candida GI colonization. These findings suggest that oral administration of S. boulardii induces a substantial but short term increase of this yeast in the intestinal lumen and administration of the probiotic does not prevent subsequent GI colonization by C. albicans.

Local complications of erysipelas: a study of associated risk factors.

BACKGROUND: Local complications of erysipelas include haemorrhagic, bullous, abscessing and necrotic lesions. The risk factors predisposing patients to local complications are not fully known. AIM: To examine local complications of erysipelas and to identify possible risk factors predisposing to their appearance. METHODS: Medical records from all patients hospitalized with complications of erysipelas (purpura, bullae, abscesses and necrosis), admitted to the University Hospital of Heraklion between 1994 and 2002, were retrospectively studied. Clinical and laboratory data were compared with those from patients with erysipelas without local complications. RESULTS: In total, 145 patients were analysed, of whom 46 had local disease complications. Using bivariate analysis, the factors significantly associated with disease complications were found to be age ≥ 51 years, obesity, longer duration of local symptoms, and fever on admission. During hospitalization, increased C-reactive protein level, isolation of pathogens, longer duration of fever and/or presence of leucocytosis, absence of response to initial antibiotic therapy, and longer length of hospitalization were also associated with complications in the bivariate analysis. However, in the multivariate analysis, obesity (OR 4.489, 95% CI 1.719-11.725, P = 0.002) was the only independent factor associated with complicated erysipelas. CONCLUSIONS: This study found obesity to be an independent risk factor for local complications, of erysipelas. Hence, obese patients with erysipelas are prone to complications, and should be carefully evaluated because of the potential severity of disease and the increased risk of failure of empirical antimicrobial therapy.

Serotypes and susceptibilities of paediatric clinical isolates of Streptococcus pneumoniae in Crete, Greece, before and after the heptavalent pneumococcal conjugate vaccine.

All Streptococcus pneumoniae strains isolated from paediatric clinical samples at Heraklion University General Hospital in the 10-year period 2000-2009 were tested for serotype and susceptibility to antimicrobials. Among a total of 258 strains, 159 were isolated in the 5-year period 2000-2004, before the introduction of the heptavalent pneumococcal conjugate vaccine (PCV7), and 99 in the post-PCV7 5-year period 2005-2009. The prevalence of PCV7-included serotypes decreased in the post-PCV7 period (p = 0.0002), but an increase was observed for serotypes 7F (p = 0.002) and 19A (p = 0.004). Pan-susceptibility rates and susceptibility to cotrimoxazole increased in the post-PCV7 period (p = 0.01 and p = 0.008, respectively), but serotype 19A emerged as a contributor to multi-resistance (p = 0.007). PCV7 was followed by decreased S. pneumoniae resistance and prevalence of vaccine-related serotypes but increased prevalence of serotypes 7F and 19A. Continuing surveillance is required after the recent introduction of PCV10 and PCV13.

Serotype distribution and antimicrobial resistance of adult Streptococcus pneumoniae clinical isolates over the period 2001-2008 in Crete, Greece.

BACKGROUND: We report on the serotype distribution and the antimicrobial susceptibility patterns (ASP) to 19 antibiotics of 195 Streptococcus pneumoniae isolates (41 invasive) collected over the period 2001-2008 from adult patients. MATERIAL AND METHODS: Pneumococcal isolates were serotyped by the Quellung reaction, and ASP testing was performed using E-test. RESULTS: Isolates with intermediate and high-level resistance to penicillin increased from 17 and 12.4% over the period 2001-2004 to 31.1 and 16.7% over the years 2005-2008, respectively (p = 0.03). Macrolide resistance increased from 27.6 to 38.9%, but this was not significant (p = 0.13), while resistance to trimethoprim-sulfamethoxazole did not change over time, with approximately one fourth of the isolates being resistant. Only one isolate was resistant to fluoroquinolones. Multi-resistance was observed among 42 (58.1%) penicillin non-susceptible strains. The isolates tested belonged to 20 different serotypes. Serotypes 19F and 19A were the most common among penicillin-resistant isolates. The currently licensed 23-valent pneumococcal polysaccharide vaccine covered 98.4% of all 186 typeable S. pneumoniae strains. CONCLUSION: Our study emphasizes the importance of continued serotyping and surveillance of antimicrobial susceptibility of all S. pneumoniae clinical isolates, especially invasive ones, in order to guide the clinician in the choice of appropriate empirical antibiotic therapy for serious pneumococcal infections.