Is living in a border region a risk for a high prevalence of resistance?

This study assessed the antimicrobial resistance and population structure of Staphylococcus aureus isolated from general practice (GP) patients and nursing home (NH) residents in the province of Limburg (near the border with Germany and Belgium) in comparison with those obtained in the remaining provinces of the Netherlands. A total of 617 and 418 S. aureus isolates were isolated from 2,691 to 1,351 nasal swabs from GP patients and NH residents, respectively. Quantitative antibiotic susceptibility testing was performed using a microbroth dilution method. Putative methicillin-resistant S. aureus (MRSA) isolates were tested for the presence of the mecA gene and spa typing was performed on all S. aureus isolates. No significant differences in the prevalence of resistance were found between the two groups of GP isolates, but the isolates from the NH residents showed a lower resistance for trimethoprim-sulfamethoxazole (p = 0.003) in Limburg province compared with the remaining provinces in the Netherlands. Among the isolates from NH residents in Limburg province, the prevalence of spa-CC 084 was higher (p = 0.003) and that of spa-CC 002 was lower (p = 0.01) compared with isolates from NHs in the remaining provinces of the Netherlands. We observed no differences in resistance and population structure between S. aureus isolates from GP patients in Limburg and the remaining provinces of the Netherlands, and only a few differences were observed between the NH populations. There was no higher prevalence of resistance among the GP and NH isolates from Limburg compared with the remaining provinces.

Short- and long-term recovery of upper limb function after axillary lymph node dissection.

All breast cancer patients, suspected with lymph node invasion, need an axillary lymph node dissection. This study investigated the short- and long-term effects of the treatment for breast cancer on shoulder mobility, development of lymphoedema, pain and activities of daily living. Patients who had a modified radical mastectomy (33%) or a breast-conserving procedure (67%) in combination with axillary lymph node dissection were included. Shoulder mobility, lymphoedema, pain and activities of daily living were evaluated at 3 months and at 3.4 years after surgery. At long term, 31% of the patients experienced impaired shoulder mobility, 18% developed lymphoedema, 79% had pain and 51% mentioned impaired daily activities. Between 3 months and 3.4 years after surgery, impaired shoulder mobility decreased from 57% to 31%. The incidence of lymphoedema increased from 4% to 18%. Patients experienced an equal amount of pain but fewer problems with daily activities. At 3.4 years, no significant differences between mastectomy and breast-conserving procedure were found. In conclusion, at long term, significant number of breast cancer survivors still had impaired shoulder mobility, developed lymphoedema, had pain and experienced difficulties during daily activities. Shoulder mobility, pain and daily activities evolved positively, while the incidence of lymphoedema increased.

Urinary tract infection in male general practice patients: uropathogens and antibiotic susceptibility.

OBJECTIVES: To evaluate uropathogens and their antibiotic susceptibility in male general practitioner (GP) patients presenting with an uncomplicated urinary tract infection (UTI). MATERIAL AND METHODS: A population-based study was conducted among males, 18 years and older, general practice patients, who had symptoms indicative of an uncomplicated UTI. A UTI was defined as >/=10(3) colony-forming units/mL (CFU/mL). The etiology of the infection, antimicrobial susceptibility, and treatment strategies used by the GP were determined. RESULTS: Escherichia coli was most frequently isolated (48%), followed by other enterobacteriaceae (24%) and enterococci (9%). The etiology of infection was age-dependent; E. coli was more frequently isolated in younger patients and Pseudomonas aeruginosa in the elderly. The overall susceptibility rates were low for amoxicillin (63%) and trimethoprim (70%), and high for fluoroquinolones (91%) and amoxicillin-clavulanic acid (90%), which is similar to susceptibility rates in females with UTIs from the same population. Antibiotics were prescribed to 59% of the males with symptoms of UTI. Fluoroquinolones were given to 33% of the patients and trimethoprim-sulfamethoxazole to 24%. No difference in antibiotic prescription, nor in duration of therapy, was found between the different age groups. CONCLUSIONS: In the male presenting with complaints of an acute uncomplicated UTI at the GP, E. coli, followed by other Gram-negative bacteria were the most frequently isolated uropathogens. Susceptibility rates in uncomplicated male and female UTIs were similar, indicating that data from UTI susceptibility studies in females from the same geographic region can be useful in the choice of empirical therapy in males.

Comparison of Copan eSwab with the Copan Venturi Transystem for the quantitative survival of Escherichia coli, Streptococcus agalactiae and Candida albicans.

Swab transport systems should preserve the viability and stability of micro-organisms in clinical specimens throughout transport and storage. eSwab, a nylon-tipped swab in liquid medium, designed for better specimen collection and less micro-organism entrapment, was evaluated for the maintenance of viability and quantitative survival of Escherichia coli, Streptococcus agalactiae and Candida albicans. The quantitative elution method was used to evaluate eSwab in vitro. In vitro, the recovery of the three micro-organisms was higher in eSwab (97-100%) as compared to the Copan Venturi Transystem (CVT) (86-96%) at room temperature (RT) for time point 0 h and remained similar after 6 h. E. coli and C. albicans proliferated in both transport systems when preserved beyond 6 h. At 4 degrees C, the recovery of eSwab was higher (>94%) compared to CVT (77-94%) for the micro-organisms tested. eSwab did not only meet the Clinical Laboratory and Standards Institute (CLSI) criteria for microbiological transport devices, but as its recovery rate in vitro was higher than that of CVT, it might also enhance the sensitivity of bacterial culture in the future.

The population structure of Staphylococcus aureus among general practice patients from The Netherlands.

To investigate the prevalence, the antibiotic resistance pattern and the population structure of Staphylococcus aureus, S. aureus isolates from the anterior nostrils of patients of general practitioners (GPs) were analysed. Insight into the S. aureus population structure is essential, as nasal carriers of S. aureus are at increased risk of developing an S. aureus infection. S. aureus was isolated from nasal swabs from 2691 patients with no sign of an infection collected in 29 GP practices in The Netherlands. The susceptibility pattern for several classes of antibiotics was determined, as well as the S. aureus genetic background, using spa typing. S. aureus was isolated from 617 of the 2691 (23%) nasal swabs. The prevalences of resistance to ciprofloxacin, co-trimoxazole, fusidic acid, macrolides and mupirocin were 0.2%, 0%, 6%, 5% and 1%, respectively. Half of the isolates were associated with a genetic background common to the major methicillin-resistant S. aureus (MRSA) clones, e.g. clonal complex (CC)1, CC5, CC8, CC22, CC30 and CC45, and the remainder were mainly associated with CC7, CC12, CC15, CC26, CC51 and CC101. The low prevalences of resistance suggest that, in the Dutch situation, S. aureus isolates from patients visiting their GP because of complaints not related to infection do not represent a large reservoir of antibiotic resistance genes. Although no MRSA isolates were found, the genetic background of some of the S. aureus isolates is commonly observed among community-associated (CA)-MRSA clones (CC1, CC8 and CC30), and this might suggest that these isolates have the potential to become CA-MRSA.

Fosfomycin tromethamine as second agent for the treatment of acute, uncomplicated urinary tract infections in adult female patients in The Netherlands?

BACKGROUND: Uncomplicated urinary tract infections (UTIs) are common among female patients. According to the national guidelines of the Dutch College of General Practitioners (GPs), the drugs of first and second choice as therapy for UTIs are nitrofurantoin and trimethoprim with resistance percentages of 2% and 23%, respectively. The third choice is fosfomycin tromethamine for which no current resistance data from The Netherlands are available. The aim of this study was to determine these resistance percentages. METHODS: During 2003-04, urine samples were collected from a representative sample of 21 general practices spread over The Netherlands, the Sentinel Stations of The Netherlands Institute for Health Services Research (NIVEL). Escherichia coli isolated from female patients visiting their GP with symptoms of an acute, uncomplicated UTI were used. Fosfomycin tromethamine susceptibility was determined by Etests. An MIC of fosfomycin tromethamine of 64 mg/L or lower was considered to indicate susceptibility, and MIC values of 96 mg/L or higher were considered to indicate resistance. E. coli ATCC 25922 was used as a reference strain. RESULTS: In total, 1705 E. coli strains were tested, of which 11 (0.65%) were resistant to fosfomycin tromethamine. The MIC(50) and MIC(90) values for this population were 1 and 4 mg/L, respectively. Within the inhibition zone of 162 susceptible E. coli, resistant mutant colonies were observed, of which after repetition of the susceptibility testing 68 were resistant. In total, 79 (5%) strains were resistant to fosfomycin tromethamine. There was no cross-resistance observed between fosfomycin tromethamine and other antimicrobial agents tested previously. CONCLUSIONS: The high in vitro susceptibility to fosfomycin tromethamine in this population and the lack of cross-resistance between fosfomycin tromethamine and other agents together with the extensive global clinical experience support the choice of the national guidelines of the Dutch College of GPs to include fosfomycin tromethamine as a therapeutic option in general practice for uncomplicated UTIs.

[Non-antibiotic prophylaxis for recurrent urinary-tract infections]. / Niet-antibiotische profylaxe van recidiverende urineweginfecties.

Urinary-tract infections (UTIs) occur frequently and hence have significant financial implications. Antibiotic prophylaxis can be considered in women with recurrent UTIs. However, frequent exposure to antibiotics can lead to antimicrobial resistance and side effects. The most important steps in the pathogenesis of UTIs are the colonisation and adherence of uropathogens. Lactobacilli impede intravaginal colonisation by competing with uropathogens. Cranberries interfere with the adherence of uropathogens to uroepithelial cells. Therefore, cranberries and lactobacilli are potential alternatives in the prophylaxis of UTIs. Randomised clinical trials comparing these compounds with long-term, low-dose antibiotics for the prevention of recurrent UTIs in women have not yet been conducted. Such a trial has recently been started in The Netherlands: the 'Non-antibiotic versus antibiotic prophylaxis for recurrent urinary-tract infections' (NAPRUTI) study.

Erythromycin resistance in the commensal throat flora of patients visiting the general practitioner: a reservoir for resistance genes for potential pathogenic bacteria.

The prevalence and mechanism of erythromycin resistance in commensal throat streptococci was determined from October 2000 until December 2002 as part of an ongoing study of the NIVEL in general practice patients (N=678). Resistance prevalence for 1mg/L and 16 mg/L erythromycin was 57% and 20%, respectively. The percentage of total commensal flora resistant within each patient ranged from 1% to 100% (median, 1%). mefA was predominantly found among isolates on the 1mg/L plates, and ermB was found in 64% of the isolates on the 16 mg/L plates. Erythromycin resistance was transferred from a commensal isolate to Streptococcus pneumoniae with a frequency of 1 x 10(-9). Commensal streptococci of general practice patients in The Netherlands form a large reservoir of transferable erythromycin resistance (genes) for potential pathogenic microorganisms.

Effect of hospitalization on the antibiotic resistance of fecal Enterococcus faecalis of surgical patients over time.

The prevalence of antibiotic resistant Enterococcus faecalis was determined in fecal samples of 263 patients admitted to the surgical wards of three university-affiliated hospitals on admission, at discharge, and at 1 and 6 months after discharge. A slight increase in the prevalence of antibiotic resistance of E. faecalis was found at discharge for the antibiotics tested compared to those on admission, vancomycin excepted. At 6 months after discharge, the prevalence of resistance for amoxicillin (0%), ciprofloxacin (3%), erythromycin (47%), and oxytetracycline (60%) decreased to the level on admission (respectively 0%, 8%, 45%, and 64%). Gentamicin resistance was the same at discharge (10%) as 1 month later (12%), but decreased 6 months after discharge (8%) to the level on admission (7%). In conclusion, hospitalization resulted in the study population in a slight increase in the prevalence of resistant fecal E. faecalis isolates at discharge, which decreased again (slowly) to the level on admission 6 months after discharge. Thus, the influence of hospitalization on the prevalence of antibiotic resistance in the extramural situation disappears between 1 and 6 months after discharge in this population.

Antibiotic resistance of faecal Escherichia coli from healthy volunteers from eight developing countries.

OBJECTIVES: To determine the prevalence of antibiotic-resistant faecal Escherichia coli from adult volunteers from urban (U) areas in Kenya, Mexico, Peru and the Philippines, and non-urban (NU) locations in Curacao, Mexico, Venezuela, Ghana, Zimbabwe and the Philippines. METHODS: Faecal samples of adult volunteers (n=1290) were analysed in one laboratory for the presence of antimicrobial-resistant E. coli using Eosin Methylene Blue agar plates containing, respectively, ampicillin, oxytetracycline, cefazolin, ciprofloxacin, gentamicin, chloramphenicol and trimethoprim at breakpoint concentrations. RESULTS: The mean age of the volunteers was approximately 35 years; most of them were female. Ciprofloxacin resistance was in the range 1%-63%: the highest percentages were found in the urban populations of Asia and South America. In Peru and the Philippines (U and NU), the prevalence of gentamicin resistance was >20%. Cefazolin resistance was the highest in the urban Philippines (25%). Higher prevalences for ampicillin, oxytetracycline and trimethoprim were found for urban areas compared with non-urban ones of Asia, Africa and South America, respectively (P<0.05). CONCLUSIONS: In the populations studied, antibiotic resistance in faecal E. coli from adult volunteers was emerging for cefazolin, gentamicin and ciprofloxacin and was high for the older drugs ampicillin, oxytetracycline, trimethoprim and chloramphenicol.

Hospitalization, a risk factor for antibiotic-resistant Escherichia coli in the community?

OBJECTIVE: The impact of hospitalization on the prevalence of resistant Escherichia coli in the intestinal flora of patients admitted to the surgical wards of three Dutch university-affiliated hospitals was analysed prospectively. METHODS: Faecal samples were obtained on admission to the hospital, at the time of discharge, and 1 and 6 months after discharge. All samples were examined for resistance to nine antibiotic agents. RESULTS: For the total patient population, no significant differences in the prevalence of resistance were observed at the different sampling intervals, except for a significant decrease in cefazolin resistance between the time of discharge and 6 months after discharge (10% to 3%, P < 0.05). This decrease was mainly observed in patients from the university hospital Maastricht (azM), in which a significant decrease from 17% to 6% was detected (P < 0.05). Moreover, despite dissimilarities in patient characteristics and the marked variations in antibiotic use, no significant differences in the prevalence of antibiotic resistance were observed between the three hospitals, except for the overall higher prevalence of cefazolin-resistant E. coli in azM patients (P < 0.05). CONCLUSION: In this study, hospitalization did not seem to have any substantial effect on the prevalence of antibiotic-resistant E. coli at the different time intervals. However, as our study population consisted of surgical patients with a relatively moderate antibiotic use, and the prevalence of antibiotic resistance was only analysed for faecal E. coli, further investigation should be encouraged, as the understanding of the interaction between different resistance reservoirs is important for directing future intervention studies.