Prevalence and antibiotic resistance of commensal Streptococcus pneumoniae in nine European countries.

The human microbiota represents an important reservoir of antibiotic resistance. Moreover, the majority of antibiotics are prescribed in primary care. For this reason, we assessed the prevalence and antibiotic resistance of nasal carriage strains of Streptococcus pneumoniae, the most prevalent bacterial causative agent of community-acquired respiratory tract infections, in outpatients in nine European countries. Nasal swabs were collected between October 2010 and May 2011, from 32,770 patients, recruited by general practices in nine European countries. Overall prevalence of S. pneumoniae nasal carriage in the nine countries was 2.9%. The carriage was higher in men (3.7%) than in women (2.7%). Children (4-9 years) had a higher carriage prevalence (27.2%) compared with those older than 10 years (1.9%). The highest resistance observed was to cefaclor. The highest prevalence of multidrug resistance was found in Spain and the lowest prevalence was observed in Sweden.

Comparison of urine samples and penile swabs for detection of human papillomavirus in HIV-negative Dutch men.

OBJECTIVES: Penile swab sampling is the method of choice when testing for human papillomavirus (HPV) in men. Urine sampling is already used in routine sexually transmitted infections (STI) diagnostics and could provide a less invasive sampling method in men to detect HPV. Therefore we compared detection of HPV types in urine samples and penile swabs by the highly sensitive SPF10-LiPA25 system. METHODS: First void urine and self-obtained penile swab samples were collected from 120 men, with a mean age of 29.4 years, visiting a STI clinic in South Limburg, the Netherlands. In total 111 of 120 men were included in the analysis. Broad-spectrum HPV DNA amplification and mucosal HPV genotyping were performed using the SPF10 DEIA-LiPA25 system (SPF10 HPV LiPA, V.1). RESULTS: In total 75 (68%) men were positive for HPV in the combined analysis. Sixty-six (59%) paired samples were concordant in being positive or negative. In 39% of the men HPV DNA was detected only in the penile swab. In 2% of the men HPV DNA was detected only in the urine sample. Considering penile swabs as the gold standard, a sensitivity of 41% (95% CI 30% to 53%) and a specificity of 95% (95% CI 81% to 99%) was found. In 6 (5%) urines high risk types were repeatedly found that were not detected in the matching swab. CONCLUSIONS: Urine samples are not comparable to penile swabs in the detection of HPV in men. However, the addition of urine samples to penile swabs could be of use in epidemiological or clearance studies.

Evaluation of phenotypic and molecular methods for identification of Streptococcus pneumoniae.

AIM: The objective of this study is to compare various Streptococcus pneumoniae identification methods. MATERIALS & METHODS: In total, 1371 putative S. pneumoniae isolates were tested with three phenotypic methods and a molecular-based method targeting a virulence factor (CpsA). We assessed the sensitivity and the specificity of each method and widely used S. pneumoniae identification algorithm. RESULTS: None of the methods or the identification algorithm used separately was able to correctly identify all S. pneumoniae isolates. Furthermore, a high rate of optochin resistance was found. CONCLUSIONS: We demonstrated the failure of the current S. pneumoniae identification methods and optochin susceptibility-based algorithm. In addition, the high rate of optochin resistance might justify the necessity of a close monitoring of optochin susceptibility.

Evaluation of Vancomycin Prediction Methods Based on Estimated Creatinine Clearance or Trough Levels.

BACKGROUND: The aim of this study was to investigate whether vancomycin clearance (CLva) can be adequately predicted with CLva prediction methods. Additionally, other covariates influencing the CLva were investigated and predictivity of monitoring of only trough levels to 24-hour area under the curve (AUC24) was evaluated. METHODS: Routine vancomycin plasma levels were measured with a fluorescence polarization immunoassay. Pharmacokinetic (PK) parameters of individual patients, that is, CLva and volume of distribution, were determined with maximum a posteriori Bayesian estimation. CLva was calculated with the 3 prediction methods, which are solely based on creatinine clearance (CLcr) estimated with Cockcroft and Gault formula and was compared with the calculated CLva with maximum a posteriori Bayesian estimation. Prediction errors were calculated. Correlations between CLva and CLcr, creatinine, age, weight, sex, and neutropenia were made. Furthermore, correlations between trough levels and AUC24 were evaluated. RESULTS: A total of 171 patients were included. Prediction errors and absolute prediction errors of the 3 methods ranged from 28% to 80% and 39% to 83%, respectively. In the multivariate analysis, CLva was significantly associated with CLcr, creatinine, age, weight, sex, and neutropenia. Linear correlation between AUC24 and trough levels was R(2) 0.38. CONCLUSIONS: Large prediction errors make the CLva algorithms based on estimated plasma CLcr unsuitable for use in patient care. Additionally, other factors, which are not accounted for in the current algorithms, influence the CLva individually. Owing to low association of AUC24 and trough levels, the AUC24 cannot be predicted with through levels. For a reliable AUC24 guided vancomycin dosing, therapeutic drug monitoring is necessary.

Confirmation of high specificity of an automated enzyme immunoassay test for serological diagnosis of syphilis: retrospective evaluation versus results after implementation.

BACKGROUND: The optimal algorithm for serological syphilis screening is still a matter of debate. We have previously evaluated the performance of the Bioelisa Syphilis 3.0, using a selection of archived sera, and in this study compare these results with the Bioelisa results after clinical implementation. METHODS: All Bioelisa Syphilis 3.0 results obtained since clinical implementation were analyzed. Bioelisa-positive or borderline samples were retested using Treponema pallidum particle agglutination, rapid plasma reagin test, fluorescent treponemal antibody-absorption test, and/or immunoblot. On sera sent in together with cerebrospinal fluid, occasionally both the T. pallidum particle agglutination and Bioelisa were performed. RESULTS: The Bioelisa was performed on 14,622 sera. Bioelisa-positive samples, which were not retested by the previously described assays, were withdrawn from the database (n = 36). In 1.3% of the samples (187/14,586), the Bioelisa was positive or borderline and, ultimately, 115 sera were considered true positive (prevalence 0.8%). The specificity of the Bioelisa was 99.5%. CONCLUSIONS: Based on the results of all performed diagnostic assays, the specificity of the Bioelisa of 99.5% is very consistent with that found in the initial study (100%; 95% confidence interval was 98.0%-100%). Interpreting (positive) test results is difficult in the absence of a gold standard, especially when the disease prevalence is low. Results should be viewed in the light of the patients' characteristics.

Haemophilus influenzae increases the susceptibility and inflammatory response of airway epithelial cells to viral infections.

Nontypeable Haemophilus influenzae (NTHI), a common colonizer of lungs of patients with chronic obstructive pulmonary disease (COPD), can enhance expression of the cellular receptor intercellular adhesion molecule 1 (ICAM-1), which in turn can be used by major group human rhinoviruses (HRVs) for attachment. Here, we evaluated the effect of NTHI-induced up-regulation of ICAM-1 on viral replication and inflammatory responses toward different respiratory viruses. Therefore, human bronchial epithelial cells were pretreated with heat-inactivated NTHI (hi-NTHI) and subsequently infected with either HRV16 (major group), HRV1B (minor group), or respiratory syncytial virus (RSV). Pretreatment with hi-NTHI significantly up-regulated ICAM-1 in BEAS-2B cells and primary bronchial epithelial cells. Concomitantly, release of infectious HRV16 particles was increased in cells pretreated with hi-NTHI. Pretreatment with hi-NTHI also caused a significant increase in HRV16 RNA, whereas replication of HRV1B and RSV were increased to a far lesser extent and only at later time points. Interestingly, release of IL-6 and IL-8 after RSV, but not HRV, infection was synergistically increased in hi-NTHI-pretreated BEAS-2B cells. In summary, exposure to hi-NTHI significantly enhanced sensitivity toward HRV16 but not HRV1B or RSV, probably through ICAM-1 up-regulation. Furthermore, hi-NTHI pretreatment may enhance the inflammatory response to RSV infection, suggesting that preexisting bacterial infections might exaggerate inflammation during secondary viral infection.

Vancomycin dosing in neutropenic patients.

BACKGROUND: To compare vancomycin pharmacokinetic parameters in patients with and without neutropenia. METHODS: Patients ≥18 years admitted on general wards were included. Routinely vancomycin trough and peak plasma concentrations were measured with a fluorescence polarization immunoassay. Pharmacokinetic parameters of individual patients were determined with maximum a posterior Bayesian estimation (MW Pharm 3.60). Neutropenia was defined as neutrophils <0.5×109 cells/L. PRINCIPAL FINDINGS: A total of 171 patients were included. Patients with neutropenia (n = 56) had higher clearance of vancomycin (CLva), 67 (±26) mL/min, compared to patients without neutropenia (n = 115), CLva 50 (±22) mL/min (p<0.001). No significant difference was found in serum creatinine and vancomycin volume of distribution. Neutropenia was positively associated with CLva, independently of relevant co-variables (B: 12.122, 95%CI: 1.095 to 23.149, p = 0.031). On average patients with neutropenia needed 33% higher doses of vancomycin to attain adequate exposure, i.e. AUC24≥400 mg×h/L. Furthermore, 15 initially neutropenic patients in our study group received vancomycin for a second administration period. Ten patients received the second administration period during another neutropenic period and 5 patients during a non-neutropenic phase. All 5 patients with vancomycin during both neutropenic and non-neutropenic phase had higher CLva (91 (±26) mL/min) during the neutropenic period and lower CLva (45 (±10) mL/min) during the non-neutropenic phase (p = 0.009). CONCLUSION: This study shows that most patients with neutropenia have augmented CLva. In a small group of patients that received vancomycin during two episodes, the augmented CLva seems to be reversible in the non-neutropenic period. Our data indicate that it is important to increase the daily dose with one third in patients with neutropenia (from 15 mg/kg twice daily to 13 mg/kg three times daily). Frequent performance of therapeutic drug monitoring in patients with neutropenia may prevent both therapy failure due to low AUCs and overcomes toxicity due to high vancomycin trough concentrations during recovery from neutropenia.

Primary care treatment guidelines for skin infections in Europe: congruence with antimicrobial resistance found in commensal Staphylococcus aureus in the community.

BACKGROUND: Over 90% of antibiotics for human use in Europe are prescribed in primary care. We assessed the congruence between primary care treatment guidelines for skin infections and commensal Staphylococcus aureus (S. aureus) antimicrobial resistance levels in community-dwelling persons. METHODS: The prevalence of antimicrobial resistance in S. aureus was analysed by taking nose swabs from healthy primary care patients in nine European countries (total N = 32,032). Primary care treatment guidelines for bacterial skin infections were interpreted with respect to these antimicrobial resistance patterns. First- and second-choice recommendations were assessed and considered congruent if resistance to the antibiotic did not exceed 20%. RESULTS: We included primary care treatment guidelines for impetigo, cellulitis, folliculitis and furuncle. Treatment recommendations in all countries were consistent: most of the first-choice recommendations were beta-lactams, both for children and adults. Antimicrobial resistance levels were low, except for penicillin (on average 73% resistance). Considerable variation in antimicrobial resistance levels was found between countries, with Sweden displaying the lowest levels and Spain the highest. In some countries resistance to penicillin and azithromycin was significantly higher in children (4-17 years) compared with adults. CONCLUSIONS: Most of the first- and second-choice recommendations in the treatment guidelines for skin infections were congruent with commensal S. aureus antimicrobial resistance patterns in the community, except for two recommendations for penicillin. Given the variation in antimicrobial resistance levels between countries, age groups and health care settings, national data regarding antimicrobial resistance in the community should be taken into account when updating or developing primary care treatment guidelines.

Molecular epidemiology of Pneumocystis jiroveci in human immunodeficiency virus-positive and -negative immunocompromised patients in The Netherlands.

Pneumocystis jiroveci infections can cause pneumocystis pneumonia (PCP) or lead to colonization without signs of PCP. Over the years, different genotypes of P. jiroveci have been discovered. Genomic typing of P. jiroveci in different subpopulations can contribute to unravelling the pathogenesis, transmission and spread of the different genotypes. In this study, we wanted to determine the distribution of P. jiroveci genotypes in immunocompetent and immunocompromised patients in The Netherlands and determine the clinical relevance of these detected mutations. A real-time PCR targeting the major surface glycoprotein gene (MSG) was used as a screening test for the presence of P. jiroveci DNA. Samples positive for MSG were genotyped based on the internal transcribed spacer (ITS) and dihydropteroate synthase (DHPS) genes. Of the 595 included bronchoalveolar lavage fluid samples, 116 revealed the presence of P. jiroveci DNA. A total of 52 of the 116 samples were ITS genotyped and 58 DHPS genotyped. The ITS genotyping revealed 17 ITS types, including two types that have not been described previously. There was no correlation between ITS genotype and underlying disease. All ITS- and DHPS-genotyped samples were found in immunocompromised patients. Of the 58 DHPS-genotyped samples, 50 were found to be WT. The other eight samples revealed a mixed genotype consisting of WT and type 1. The majority of the latter recovered on trimethoprim-sulfamethoxazole suggesting no clinical relevance for this mutation.

Is the standard dose of amoxicillin-clavulanic acid sufficient?

BACKGROUND: The pharmacodynamic (PD) efficacy target of amoxicillin is 40% time above the minimal inhibition concentration (40%T > MIC). Recent studies of other antibiotics have shown that PD-efficacy targets are not always reached. The aim of this study was to evaluate the percentage of hospitalised patients, using amoxicillin/clavulanic acid intravenously (iv), that reach the pharmacodynamic efficacy target 40%T > MIC. Additionally, the association of demographic anthropomorphic and clinical parameters with the pharmacokinetics and pharmacodynamics of amoxicillin were determined. METHODS: In serum of 57 hospitalised patients amoxicillin concentrations were measured using high performance liquid chromatography. Patients were older than 18 years and most patients had an abdominal infection. The standard amoxicillin/clavulanic acid dose was 4 times a day 1000/200 mg iv. Pharmacokinetic parameters were calculated with maximum a posteriori Bayesian estimation (MW\Pharm 3.60). A one-compartment open model was used. Individual dosing simulations were performed with MW\Pharm. RESULTS: In our study population, the mean (±SD) age was 67 (±16) years and the mean clearance corrected for bodyweight was 0.17 (±0.07) L/h/kg. Only, 65% of the patients reached the proposed amoxicillin 40%T > MIC with amoxicillin/clavulanic acid for bacterial MICs of 8 mg/L. A computer simulated increase of the standard dose to 6 times daily, increased this percentage to 95%. In this small study group 40%T > MIC was not associated with clinical or microbiological cure. CONCLUSION: A substantial proportion of the hospitalised patients did not reach the 40%T > MIC with the standard dose amoxicillin/clavulanic acid for a bacterial MIC of 8 mg/L. Therefore, we suggest increasing the standard dose of amoxicillin/clavulanic acid to 6 times a day in patients with severe Enterobacteriaceae infections. TRIAL REGISTRATION NUMBER: NTR1725 16th march 2009.

Efficacy of IFN-λ1 to protect human airway epithelial cells against human rhinovirus 1B infection.

Impaired interferon (IFN) production has been observed in various obstructive respiratory diseases. This contributes to enhanced sensitivity towards viral infections triggering acute exacerbations. To compensate for this impaired host IFN response, there is need to explore new therapeutic strategies, like exogenous administration of IFNs as prophylactic treatment. In the present study, we examined the protective potential of IFN-λ1 and compared it with the previously established protecting effect of IFN-ß. A549 cells and human primary bronchial epithelial cells were first treated with either IFN-ß (500 IU/ml) or IFN-λ1 (500 ng/ml) for 18 h. For infection, two approaches were adopted: i) Continuous scenario: after pre-treatment, cells were infected immediately for 24 h with human rhinovirus 1B (HRV1B) in IFN-containing medium, or were cultured for another 72 h in IFN-containing medium, and then infected for 24 h with HRV1B, ii) Pre-treatment scenario: IFN-containing medium was replaced after 18 h and cells were infected for 4 h either immediately after pre-treatment or after additional culturing for 72 h in IFN-free medium. The protective effect was evaluated in terms of reduction in the number of viral copies/infectious progeny, and enhanced expression of IFN-stimulated genes (ISGs). In both cell types and in both approaches, IFN-λ1 and IFN-ß treatment resulted in pronounced and long-lasting antiviral effects exemplified by significantly reduced viral copy numbers and diminished infectious progeny. This was associated with strong up-regulation of multiple ISGs. However, in contrast to the IFN-ß induced expression of ISGs, which decreased over time, expression of ISGs induced by IFN-λ1 was sustained or even increased over time. Here we demonstrate that the protective potential of IFN-λ1 is comparable to IFN-ß. Yet, the long-lasting induction of ISGs by IFN-λ1 and most likely less incitement of side effects due to more localized expression of its receptors could make it an even more promising candidate for prophylactic treatment than IFN-ß.

Microbiology of surgical site infections after gastrointestinal surgery in the south region of The Netherlands.

AIM: To give an overview of the microbiology of blood and wound samples from surgical site infections (SSIs) after gastrointestinal surgery, as well as the antimicrobial susceptibility of the microorganisms involved, and to discuss the appropriateness of the prophylactic antibiotics administered. MATERIALS & METHODS: During a 3.5-year study period, wound swabs and blood samples of patients with an SSI were taken in the first 48 h after surgery until 30 days thereafter. RESULTS: Most pathogens were isolated from wound swabs. Escherichia coli (25%) and Pseudomonas aeruginosa (10%) were the most frequently found microorganisms. Both microorganisms showed a slight tendency towards a decrease in susceptibility for the tested antibiotics, although after correction, this was not significant. CONCLUSION: The comparison between wound swabs taken in the first 48 h after a surgical procedure and swabs in the 30 days thereafter provides important information concerning the microbiology of SSIs and the development of antibiotic resistance of the causative agents over time.

Evidence-based primary care treatment guidelines for skin infections in Europe: a comparative analysis.

BACKGROUND: In Europe, most antibiotics for human use are prescribed in primary care. Incorporating resistance data into treatment guidelines could improve appropriate prescribing, increase treatment effectiveness and control the development of resistance. OBJECTIVES: This study reviews primary care treatment guidelines for bacterial skin infections across Europe and assesses to what extent they are based on antibiotic resistance data. METHODS: Thirteen primary care treatment guidelines were obtained from eight countries across Europe. Both the treatment recommendations and the underlying evidence were assessed. The class and dose of recommended antibiotics were investigated and compared using the World Health Organisation's standardized volume of Defined Daily Dose. Furthermore, analysis investigated whether guidelines included references to scientific publications about antibiotic resistance data, and whether these were of national origin. RESULTS: Guidelines were included regarding common skin infections in primary care: Impetigo, Cellulitis, Erysipelas, Folliculitis and Furuncle. RESULTS showed a high agreement across Europe: all recommended antibiotics are of the beta-lactam class and mainly in the small spectrum. The advised treatment durations are consistent; the dosages, however, vary considerably, with the highest dosages recommended in Sweden. Seven guidelines (54%) did not include scientific references related to resistance. CONCLUSION: There may be a lack of relevant national data on resistance. This study highlights the need to collect more national resistance data (particularly regarding beta-lactams) to create stronger evidence-based treatment guidelines for skin infections in Europe.

The host immune response contributes to Haemophilus influenzae virulence.

BACKGROUND: There is compelling evidence that infections with non-typeable Haemophilus influenzae (NTHi) are associated with exacerbations in COPD patients. However, NTHi has also been isolated frequently during clinically stable disease. In this study we tested the hypothesis that genetically distinct NTHi isolates obtained from COPD patients differ in virulence which could account for dissimilarities in the final outcome of an infection (stable vs. exacerbation). RESULTS: NTHi isolates (n = 32) were obtained from stable COPD patients, or during exacerbations. Genetically divergent NTHi isolates were selected and induction of inflammation was assessed as an indicator of virulence using different in vitro models. Despite marked genomic differences among NTHi isolates, in vitro studies could not distinguish between NTHi isolates based on their inflammatory capacities. Alternatively, when using a whole blood assay results demonstrated marked inter-, but not intra-individual differences in cytokine release between healthy volunteers irrespective of the origin of the NTHi isolate used. CONCLUSION: Results suggest that the individual immune reactivity might be an important predictor for the clinical outcome (exacerbation vs. no exacerbation) following NTHi infection.

Cross-sectional study on surveillance of surgical site infections after vascular surgery.

AIMS: To determine the incidence and risk factors for surgical site infections (SSI) after vascular surgery, to evaluate the Dutch safety bundle to reduce adverse complications and to analyze causative microorganisms of SSIs. MATERIALS & METHODS: The 3.5-year study was divided into two periods: the control period (before bundle implementation) and intervention period (after implementation). Postdischarge surveillance was performed until 30 days after surgery. Causative microorganisms from in-hospital wound swabs were determined. SSI rates between both periods were compared and a risk analysis was carried out by performing a logistic regression. RESULTS: The study included 1719 operations. The in-hospital SSI rate increased significantly over time. Out of 140 SSIs, 39% were diagnosed postdischarge. Risk factors were diabetes, age >60 years and operations classified as contaminated or dirty. Pseudomonas aeruginosa susceptibility was the highest for gentamicin (97%). All Staphylococcus aureus were methicillin susceptible. CONCLUSION: As patient demographics are important to determine the effectiveness of infection preventive measures, (postdischarge) surveillance is important for developing SSI interventions.

Association of cytomegalovirus and other pathogens with frailty and diabetes mellitus, but not with cardiovascular disease and mortality in psycho-geriatric patients; a prospective cohort study.

BACKGROUND: Studies about associations of infections with herpes viruses and other pathogens, such as Chlamydia pneumoniae (CP) and Helicobacter pylori (HP) with cardiovascular disease (CVD), diabetes mellitus (DM), frailty and/or mortality are conflicting. Since high levels of antibodies against these pathogens occur in the elderly, the role of these pathogens in morbidity and mortality of vulnerable elderly was explored. RESULTS: Blood samples of 295 community dwelling psycho-geriatric patients were tested for IgG antibodies to herpes simplex virus type 1 and 2, varicella zoster virus, Epstein Barr virus (EBV), cytomegalovirus (CMV), human herpes virus type 6 (HHV6), CP and HP. Frailty was defined with an easy-to-use previously described frailty risk score. Relative risks (RR) with 95% confidence intervals were calculated to evaluate associations between CVD, DM, frailty and pathogens. Pathogens as a predictor for subsequent mortality were tested using Kaplan Meier analyses and Cox proportional hazard models. The mean age was 78 (SD: 6.7) years, 20% died, 44% were defined as frail, 20% had DM and 49% had CVD. Presence of CMV antibody titers was associated with frailty, as shown by using both qualitative and quantitative tests, RR ratio 1.4 (95% CI: 1.003-2.16) and RR ratio 1.5 (95% CI: 1.06-2.30), respectively. High IgG antibody titers of HHV6 and EBV were associated with DM, RR ratio 3.3 (95% CI: 1.57-6.49). None of the single or combined pathogens were significantly associated with mortality and/or CVD. CONCLUSIONS: Prior CMV infection is associated with frailty, which could be in line with the concept that CMV might have an important role in immunosenescence, while high IgG titers of HHV6 and EBV are associated with DM. No association between a high pathogen burden and morbidity and/or mortality could be demonstrated.

Antimicrobial resistance among respiratory Haemophilus influenzae isolates from pulmonology services over a six-year period.

BACKGROUND: Respiratory tract infections (RTI) are frequently caused by Haemophilus influenzae. Widespread antibacterial resistance among respiratory microorganisms complicates empirical RTI treatment. Therefore, national data on antibiotic resistance for H. influenzae are important for guiding optimal antibiotic choice. METHODS: The antibiotic susceptibility of H. influenzae strains isolated from respiratory specimens of patients admitted to the pulmonology services between 2005 and 2010 was assessed. Isolates were collected annually from 13 hospitals in the Netherlands as part of the national intramural antimicrobial resistance surveillance performed by the Dutch Working Group on Antibiotic Policy (SWAB). Breakpoints for resistance were in accordance with the criteria of the European Committee on Antimicrobial Susceptibility Testing (EUCAST). Trend analysis was performed using logistic regression analysis. RESULTS: In total, 1606 H. influenzae strains were analyzed. The prevalence of antibiotic resistance to amoxicillin, co-amoxiclav, doxycycline, co-trimoxazole, and clarithromycin was stable over the 6-y period, and there was a trend towards a decrease in the prevalence of beta-lactamase-producing isolates. Regarding prevalences, no significant trends were observed. CONCLUSIONS: Our study showed no significant changes in antibiotic resistance for H. influenzae isolated at different hospitals in the Netherlands over a 6-y period. Regular surveillance remains important in controlling the prevalence of resistance, since actual resistance data should be taken into account when the choice of an empiric antibiotic is made.

The importance of gender-stratified antibiotic resistance surveillance of unselected uropathogens: a Dutch Nationwide Extramural Surveillance study.

Few studies have been performed on urinary tract infections (UTIs) in men. In the present study, general practitioners (n = 42) from the Dutch Sentinel General Practice Network collected urinary samples from 560 male patients (≥ 18 years) suspected of UTI and recorded prescribed antibiotic treatment. In this way, the antibiotic susceptibility of Gram-negative uropathogens, including extended-spectrum beta-lactamase (ESBL-) producing Escherichia coli could be determined. In addition, E. coli susceptibility and antibiotic prescriptions were compared with data from a similar UTI study among women and with data collected 7 years earlier. Of 367 uropathogens (66%) identified (≥ 10(3) cfu/mL), most were Gram-negative (83%) and E. coli being isolated most frequently (51%). Antibiotic susceptibility to ciprofloxacin, norfloxacin and nitrofurantoin was 94%, 92% and 88%, respectively, whereas co-amoxiclav (76%) and co-trimoxazole (80%) showed lower susceptibilities. One ESBL (0.5%) was found. A significantly higher proportion of female UTIs was caused by E. coli compared with men (72% versus 51%, P<0.05). E. coli susceptibility tended to be lower in men compared with women, although not reaching statistical significance. No changes in E. coli susceptibility were observed over time (all P>0.05). Co-amoxiclav and nitrofurantoin prescriptions increased over time (11% versus 28% and 16% versus 23% respectively, both P<0.05), whereas co-trimoxazole prescriptions decreased (24% versus 14%, P<0.05). In conclusion, given the observed gender differences in uropathogen distribution and (tendency in) E. coli antibiotic susceptibility, empirical male UTI treatment options should be based on surveillance studies including men only. When awaiting the culture result is clinically not possible, fluoroquinolones are advised as first-choice antibiotics for male UTIs in Dutch general practices based on current antibiotic susceptibility data. The prevalence of ESBL-producers was low and no differences were observed in antibiotic susceptibility over a 7-year period. In addition, antibiotic prescriptions changed in accordance with national guidelines during this time period.

A real-time PCR-based semi-quantitative breakpoint to aid in molecular identification of urinary tract infections.

This study presents a novel approach to aid in diagnosis of urinary tract infections (UTIs). A real-time PCR assay was used to screen for culture-positive urinary specimens and to identify the causative uropathogen. Semi-quantitative breakpoints were used to screen for significant bacteriuria (presence of ≥ 10(5) CFU/ml of uropathogens) or low-level bacteriuria (containing between 10(3) and 10(4) CFU/ml of uropathogens). The 16S rDNA-based assay could identify the most prevalent uropathogens using probes for Escherichia coli, Pseudomonas species, Pseudomonas aeruginosa, Staphylococcus species, Staphylococcus aureus, Enterococcus species and Streptococcus species. 330 urinary specimens were analysed and results were compared with conventional urine culture. Using a PCR Ct value of 25 as semi-quantitative breakpoint for significant bacteriuria resulted in a sensitivity and specificity of 97% and 80%, respectively. In 78% of the samples with monomicrobial infections the assay contained probes to detect the bacteria present in the urine specimens and 99% of these uropathogens was correctly identified. Concluding, this proof-of-concept approach demonstrates that the assay can distinguish bacteriuria from no bacteriuria as well as detect the involved uropathogen within 4 hours after sampling, allowing adequate therapy decisions within the same day as well as drastically reduce consequent urine culturing.

Prevalence and resistance of commensal Staphylococcus aureus, including meticillin-resistant S aureus, in nine European countries: a cross-sectional study.

BACKGROUND: Information about the prevalence of Staphylococcus aureus resistance to antimicrobial drugs has mainly been obtained from invasive strains, although the commensal microbiota is thought to be an important reservoir of resistance. We aimed to compare the prevalence of nasal S aureus carriage and antibiotic resistance, including meticillin-resistant S aureus (MRSA), in healthy patients across nine European countries. METHODS: In this cross-sectional study, nasal swabs were obtained from 32,206 patients recruited by family doctors participating in existing nationwide family doctor networks in Austria, Belgium, Croatia, France, Hungary, Spain, Sweden, the Netherlands, and the UK. Eligible patients were aged 4 years or older (≥ 18 years in the UK) and presented with a non-infectious disorder. Swabs were sent to national microbiological laboratories for identification and isolation of S aureus. Antibiotic resistance testing was done at one central microbiological laboratory. We established the genotypic structure of the isolated MRSA strains with the spa typing method. FINDINGS: S aureus was isolated from 6956 (21 · 6%) of 32,206 patients swabbed. The adjusted S aureus prevalence for patients older than 18 years ranged from 12 · 1% (Hungary) to 29 · 4% (Sweden). Except for penicillin, the highest recorded resistance rate was to azithromycin (from 1 · 6% in Sweden to 16 · 9% in France). In total, 91 MRSA strains were isolated, and the highest MRSA prevalence was reported in Belgium (2 · 1%). 53 different spa types were detected-the most prevalent were t002 (n = 9) and t008 (n = 8). INTERPRETATION: The prevalence of S aureus nasal carriage differed across the nine European countries assessed, even after correction for age, sex, and family doctor. Generally, the prevalence of resistance, including that of MRSA, was low. The MRSA strains recorded showed genotypic heterogeneity, both within and between countries. FUNDING: European Commission, 7th Framework Programme(grant agreement 223083).