Nonspecific Symptoms in Children Referred to a Lyme Borreliosis Center.

BACKGROUND: Nonspecific symptoms in children suspected of Lyme borreliosis (LB) are challenging for clinicians. We assessed whether nonspecific symptoms are more prevalent among children with positive immunoglobulin G (IgG) serology or a history of clinical LB. METHODS: We included children (<18 years) suspected of LB who visited the Lyme Center Apeldoorn of Gelre Hospital between 2008 and 2017. Serum samples were taken, and questionnaires on nonspecific symptoms completed. Clinical data were collected from patients' medical records. The prevalence of nonspecific symptoms was compared between patients with positive versus negative IgG serology and between patients with versus without previous LB with the χ and Fisher exact tests with Bonferroni correction. A history of LB was anamnestically determined. Patients with active Lyme manifestations were excluded. RESULTS: Included were 149 children (66% female; median age 13 years); 29 (19%) had positive IgG serology; 36 (24%) had previous LB; 12 (8%) had both. Common nonspecific symptoms were sleep disturbances (58%), severe fatigue (57%) and headache (42%). The prevalence of nonspecific symptoms was similar in children with positive versus negative IgG serology. None of the nonspecific symptoms occurred more frequently in children with previous LB compared with children without. More prevalent in children without previous LB were sleep disturbances (40 vs. 66%; P = 0.002) and tingling (6 vs. 34%; P < 0.001). CONCLUSIONS: Nonspecific symptoms were not more prevalent in children with positive IgG serology nor in children with previous LB, where some were significantly less prevalent. Hence, questionnaires on nonspecific symptoms cannot be used to identify children for serologic testing in Lyme centers.

Depressive Symptoms in Patients Referred to a Tertiary Lyme Center: High Prevalence in Those Without Evidence of Lyme Borreliosis.

BACKGROUND: Controversy exists whether mood disorders, such as depression, are associated with Lyme borreliosis (LB). The study objective was to assess prevalence of depressive symptoms in subgroups of patients referred to a tertiary Lyme center, to investigate whether depressive symptoms can be used in clinical practice to discriminate for LB. METHODS: This cohort study included adult patients who visited a tertiary Lyme center between January 2008 and December 2014. Prior to medical consultation, serum samples were taken and the Beck Depression Inventory II was completed to assess depressive symptoms. Lyme diagnosis was retrospectively extracted from the patient's medical record. Patients were classified based on clinical LB and serology results. Prevalence of moderate/severe depressive symptoms was calculated. Using logistic regression, odds ratios with 95% confidence intervals (CIs) were calculated for moderate/severe depressive symptoms. RESULTS: In total, 1454 patients were included. Prevalence of moderate/severe depressive symptoms was lowest in patients with no clinical LB and positive serology (15.3%), higher in patients with clinical LB with positive and negative serology (19.3% and 20.9% respectively), and highest in patients with no clinical LB and negative serology (29.3%). The odds ratio for moderate/severe depressive symptoms in patients with LB and positive serology was 0.71 (95% CI, .50-1.03) compared to patients with no LB and negative serology. CONCLUSIONS: The prevalence of depressive symptoms was similar in patients with LB compared to patients with no evidence of infection. This suggests that depressive symptoms cannot be used to discriminate for LB in a tertiary Lyme center.

Infectious aortitis with multiple mycotic aneurysms caused by Streptococcus agalactiae.

We report a case of a 66-year-old man with multiple thoracoabdominal mycotic aortic aneurysms caused by Streptococcus agalactiae (S agalactiae). The infectious aortitis (IA) was diagnosed by transesophageal echocardiography and computed tomography and confirmed by positive blood cultures. The patient was treated with antibiotics, but, after worsening of the aortitis, a successful surgical procedure was performed. A review of the literature is presented together with a series of 7 other cases of IA caused by S agalactiae.

Appropriateness of empirical treatment and outcome in bacteremia caused by extended-spectrum-ß-lactamase-producing bacteria.

We studied clinical characteristics, appropriateness of initial antibiotic treatment, and other factors associated with day 30 mortality in patients with bacteremia caused by extended-spectrum-ß-lactamase (ESBL)-producing bacteria in eight Dutch hospitals. Retrospectively, information was collected from 232 consecutive patients with ESBL bacteremia (due to Escherichia coli, Klebsiella pneumoniae, and Enterobacter cloacae) between 2008 and 2010. In this cohort (median age of 65 years; 24 patients were <18 years of age), many had comorbidities, such as malignancy (34%) or recurrent urinary tract infection (UTI) (15%). One hundred forty episodes (60%) were nosocomial, 54 (23%) were otherwise health care associated, and 38 (16%) were community acquired. The most frequent sources of infection were UTI (42%) and intra-abdominal infection (28%). Appropriate therapy within 24 h after bacteremia onset was prescribed to 37% of all patients and to 54% of known ESBL carriers. The day 30 mortality rate was 20%. In a multivariable analysis, a Charlson comorbidity index of ≥ 3, an age of ≥ 75 years, intensive care unit (ICU) stay at bacteremia onset, a non-UTI bacteremia source, and presentation with severe sepsis, but not inappropriate therapy within <24 h (adjusted odds ratio [OR], 1.53; 95% confidence interval [CI], 0.68 to 3.45), were associated with day 30 mortality. Further assessment of confounding and a stratified analysis for patients with UTI and non-UTI origins of infection did not reveal a statistically significant effect of inappropriate therapy on day 30 mortality, and these results were insensitive to the possible misclassification of patients who had received ß-lactam-ß-lactamase inhibitor combinations or ceftazidime as initial treatment. In conclusion, ESBL bacteremia occurs mostly in patients with comorbidities requiring frequent hospitalization, and 84% of episodes were health care associated. Factors other than inappropriate therapy within <24 h determined day 30 mortality.

Molecular analysis of ciprofloxacin resistance and clonal relatedness of clinical Escherichia coli isolates from haematology patients receiving ciprofloxacin prophylaxis.

OBJECTIVES: Widespread use of fluoroquinolones has led to increased levels of resistance in clinical isolates of Escherichia coli. We investigated the evolution of ciprofloxacin susceptibility and molecular epidemiology of clinical E. coli isolates in haematology patients receiving ciprofloxacin prophylaxis on the population and individual patient level. METHODS: From August 2006 through December 2007 we collected all E. coli isolates (n = 404) from surveillance and infection-site cultures from 169 haematology patients receiving ciprofloxacin prophylaxis. Analysis of the gyrase A (gyrA) gene was performed by denaturing gradient gel electrophoresis (DGGE) in 364 isolates and clonal relatedness was determined by the single-enzyme amplified fragment length polymorphism (seAFLP) technique in 162 isolates. One hundred of these isolates were also subjected to qnrA analysis. RESULTS: The average number of samples per patient was 2.4 (maximum 20) and 122 (30%) of 404 E. coli isolates were resistant to ciprofloxacin. In 124 patients only ciprofloxacin-susceptible strains were detected. DGGE revealed 11 different gyrA sequence patterns and, based on AFLP analysis, there was evidence of selection of ciprofloxacin-resistant strains under antibiotic pressure, as well as the occurrence of genetically indistinguishable ciprofloxacin-resistant and -susceptible E. coli isolates within one patient. Clonal dissemination of ciprofloxacin-resistant E. coli was observed, but did not predominate. CONCLUSIONS: The genetic evolution of clinical E. coli isolates in haematology patients receiving ciprofloxacin prophylaxis is characterized by selection of ciprofloxacin-resistant strains. However, we did find evidence for de novo resistance mutation in ciprofloxacin-susceptible E. coli in individual patients under selective pressure.

Optimizing use of ciprofloxacin: a prospective intervention study.

OBJECTIVES: Antimicrobial resistance to ciprofloxacin is increasing. The objective of this study was to reduce the number of inappropriate prescriptions and to improve the quality of ciprofloxacin prescriptions by means of educational intervention. METHODS: In a teaching hospital five units of the Departments of Internal Medicine, Gastro-Enterology, Surgery, Urology and Pulmonary Diseases, selected because of a high rate of ciprofloxacin prescription, participated in a prospective intervention study. The quantity and the quality of prescriptions were reviewed before and after educational intervention and during follow-up. The quality of each ciprofloxacin prescription was independently evaluated by two medical microbiologists. During the intervention period, a medical microbiologist discussed the appropriateness of prescribing ciprofloxacin with prescribing clinicians, and educational presentations were given to clinicians of participating units. Regression analysis was used to analyse trends in time-series data. RESULTS: The number of ciprofloxacin prescriptions decreased from 81 prescriptions/1000 admissions before intervention to 32 prescriptions/1000 admissions after intervention, a significant reduction of 60.5%. Appropriate prescriptions significantly increased. Significantly fewer inappropriate prescriptions were prescribed after intervention and/or during follow-up. At this time, 23 ciprofloxacin prescriptions/1000 admissions were prescribed, a total reduction of 71.3% compared with baseline. CONCLUSIONS: In a hospital with relatively low baseline ciprofloxacin consumption, intervention by direct consultation of a medical microbiologist and educational presentations led to 3-4-fold sustained reduction in the use of ciprofloxacin and significant improvement in quality of ciprofloxacin prescriptions. Close collaboration between clinicians and medical microbiologists can provide a major contribution to the prudent hospital use of antimicrobial agents.