Care for adult non-ICU Covid-19 patients: early experiences from a Belgian tertiary care centre.

The current Covid-19 outbreak poses many challenges on hospital organisation and patient care. Our hospital lies at the epicentre of the Belgian epidemic. On April 1st, a total of 235 Covid-19 patients had been admitted to our hospital. This demanded an unprecedented adaptation of our hospital organisation, and we have met many clinical issues in the care for Covid-19 patients. In this article, we share our experience in the handling of some of the practical and organisational issues in the care for Covid-19 patients.

Antibiotic prophylaxis in TURP: a prospective analysis concerning antibiotic stewardship and a potential reduction of antibiotic use in TURP.

PURPOSE: Antibiotic prophylaxis is standard procedure in transurethral resection of the prostate (TURP). We evaluated the necessity of antibiotic (AB) prophylaxis in TURP due to increasing microbial antibiotic resistance. METHODS: This is a prospective cohort study of 506 patients. Only patients with a pre-operative catheter/pyuria received AB-prophylaxis. Urine analysis (pre-operative, at discharge, and 3 week post-operative) was performed next to an analysis of the blood culture/irrigation fluid and of the resected prostatic tissue. Statistical analysis was performed using Fisher's exact test. RESULTS: 67/506 (13.2%) patients received prophylactic antibiotics. 56/67 (83.5%) patients had a pre-operative catheter and 11/67 (16.4%) had pre-operative pyuria in which a fluoroquinolone-resistance (FQ-R) rate of 69.2% in Escherichia coli (EC) was observed. Clinical infectious symptoms were present in 13/439 (2.9%) patients without antibiotic prophylaxis; 12/439 (2.7%) patients had uncomplicated fever (<38.5°) during or after hospitalization and only 1/439 patient (0.2%) was high degree fever (> 38.5°) observed. Uncomplicated fever developed in 7/67 (10.4%) patients who did receive AB-prophylaxis. FQ-R was observed in 60% of the positive urine cultures at discharge and in 53.8% 3 week post-operatively. CONCLUSIONS: Our data show a low infectious complication rate (2.9%) in patients without a pre-operative catheter or pyuria,undergoing TURP without AB-prophylaxis. These findings might question the current use of AB prophylaxis in TURP in patients without a pre-operative catheter or pyuria, in times of antibiotic stewardship due to the high rate of microbial-resistance in our population.

How to achieve accurate blood culture volumes: the BD BACTEC FX blood volume monitoring system as a measuring instrument and educational tool.

Collecting adequate volumes of blood in blood culture bottles is crucial for sensitive detection of bacteremia and fungemia. Tools enabling easy collection of data on the degree of blood culture bottle filling at different hospital departments are an important step toward quality measurement and improvement. In this study, we verified the accuracy of a software tool for the monitoring of blood culture bottle filling developed by Becton Dickinson, BD blood volume monitoring system (BVMS) that was adjusted for use on plastic BACTEC bottles, and evaluated its ease of use in routine practice. In total, 538 negative plastic BD BACTEC Plus Aerobic/F blood culture bottles collected in two secondary care hospitals in Belgium were included in the study. The BVMS software demonstrated good performance, with an acceptable mean difference of - 0.3 mL or - 4.0% between the mean volume estimated by BVMS and the mean weight-based volume. Data (mean blood volume and standard deviation) and figures (box-and-whisker and histogram plots) on blood culture bottle filling are easily acquired. They provide information on the current situation in a hospital (department) and can be used as a tool for quality improvement measurements and follow-up. Caution is required when interpreting BVMS results for hospital wards where a substantial amount of the bottles collected come from patients with hematocrit values < 30%. This study demonstrated that BVMS is a reliable and easy to use tool which facilitates monitoring and coordination of optimization of blood culture bottles filling by the clinical laboratory.

Technical and clinical validation of three commercial real-time PCR kits for the diagnosis of neuroborreliosis in cerebrospinal fluid on three different real-time PCR platforms.

This study reports the evaluation of the technical and clinical validation of the O-DiaBorburg kit (DIA), Borrelia burgdorferi PCR kit, ISEX (GENE), and Borrelia burgdorferi sensu lato Real-TM (SAC) for the diagnosis of neuroborreliosis in cerebrospinal fluid based on both Borrelia DNA and CSF samples from patients with clinical suspicion of neuroborreliosis. This validation study was done by analysing the kits on the Rotorgene Q (RGQ), CFX96, and LightCycler480 (LC480). For all kits, the linear range was larger on RGQ than on CFX96 and LC480. A good reproducibility was obtained for all assays on all instruments. Storage at -20 °C resulted in a decreased reproducibility for SAC. Results of the limit of detection (LOD95) experiments indicated a better sensitivity than described in the kit insert for all kits on all PCR platforms. No cross-reactivity was found for genetically related organisms nor for other pathogens which may be present in CSF. All species of the Borrelia burgdorferi sensu lato complex were detected with the GENE and SAC kits. The DIA kit failed to detect B. lusitaniae. The results seemed to indicate a better overall performance for the GENE kit on RGQ. However, its diagnostic value could not be confirmed in the clinical validation study, wherein none of the 103 CSF samples from clinical neuroborreliosis cases showed a positive real-time PCR result with the GENE kit analysed on RGQ.

Development of a national EUCAST challenge panel for antimicrobial susceptibility testing.

A challenge panel of bacterial strains useful for clinical laboratories to validate their European Committee on Antimicrobial Susceptibility Testing (EUCAST) antimicrobial susceptibility test (AST) system was established. A total of 117 strains, obtained from Belgian Reference Centres (n = 57) and from routine clinical samples (n = 60) was selected based on resistance pattern. These strains were analysed in seven different laboratories by three different automated AST systems (Vitek (n = 2), Phoenix (n = 2) and Microscan (n = 2)) and by disc diffusion from five different manufacturers (Rosco (n = 2), Becton-Dickinson (n = 2), Biomérieux (n = 1), Bio-rad (n = 1) and i2a (n = 1)). To select the challenge panel, selection criteria were set for categorical agreement between the different systems and the number of very major errors, major errors and minor errors. Very major and major errors for at least two antibiotics were observed in 43% of all strains, leading to the exclusion of these strains from the selected panel. In only 10% of all tested strains was there 100% categorical agreement for all antibiotics. Finally, 28 strains (14 Gram-positive and 14 Gram-negative) covering a wide spectrum of resistance mechanisms were selected. Pilot-testing of this challenge panel in 20 laboratories mainly confirmed the results of the validation study. Only six strains withheld for the pilot study could not be used as challenge strain due to an overall (very) major error rate of >5% for a particular antibiotic (n = 5) or for two antibiotics (n = 1). To conclude, this challenge panel should facilitate the implementation and use of EUCAST breakpoints in laboratories.

A hospital-level cost-effectiveness analysis model for toxigenic Clostridium difficile detection algorithms.

BACKGROUND: Despite thorough analyses of the analytical performance of Clostridium difficile tests and test algorithms, the financial impact at hospital level has not been well described. Such a model should take institution-specific variables into account, such as incidence, request behaviour and infection control policies. AIM: To calculate the total hospital costs of different test algorithms, accounting for days on which infected patients with toxigenic strains were not isolated and therefore posed an infectious risk for new/secondary nosocomial infections. METHODS: A mathematical algorithm was developed to gather the above parameters using data from seven Flemish hospital laboratories (Bilulu Microbiology Study Group) (number of tests, local prevalence and hospital hygiene measures). Measures of sensitivity and specificity for the evaluated tests were taken from the literature. List prices and costs of assays were provided by the manufacturer or the institutions. The calculated cost included reagent costs, personnel costs and the financial burden following due and undue isolations and antibiotic therapies. Five different test algorithms were compared. FINDINGS AND CONCLUSION: A dynamic calculation model was constructed to evaluate the cost:benefit ratio of each algorithm for a set of institution- and time-dependent inputted variables (prevalence, cost fluctuations and test performances), making it possible to choose the most advantageous algorithm for its setting. A two-step test algorithm with concomitant glutamate dehydrogenase and toxin testing, followed by a rapid molecular assay was found to be the most cost-effective algorithm. This enabled resolution of almost all cases on the day of arrival, minimizing the number of unnecessary or missing isolations.

Establishing quality control ranges for temocillin following CLSI-M23-A3 guideline.

OBJECTIVES: This study aimed to establish acceptable quality control ranges for temocillin disk diffusion tests and Etest(®) minimal inhibitory concentrations. METHODS: According to Clinical and Laboratory Standards Institute (CLSI) guideline, a Tier 2 quality control study was performed and involves seven laboratories. Each of them tested 10 replicates of two quality control strains (Escherichia coli ATCC 25922 and E. coli ATCC 35218) on three different media lots and, for disk diffusion, two disk lots. RESULTS: Proposed zone diameter quality control ranges were 12-25 mm for E. coli ATCC 25922 and 19-28 mm for E. coli ATCC 35218. Proposed Etest quality control ranges were 3-24 mg/l for E. coli ATCC 25922 and 2-6 mg/l E. coli ATCC 35218. CONCLUSION: Based on our results, we would advise the use of E. coli ATCC 35218 as QC strain for temocillin susceptibility testing and Etest because ranges obtained are narrower than with E. coli ATCC 25922 and do not overlap temocillin breakpoint.

Comparison of different phenotypic assays for the detection of extended-spectrum ß-lactamase production by inducible AmpC-producing Gram-negative bacilli.

Routine detection of extended-spectrum ß-lactamase (ESBL) production by AmpC-producing Enterobacteriaceae in microbiology laboratories is still a problem. The aim of this study was to compare the performance of four different phenotypic ESBL confirmation assays within this group of Enterobacteriaceae. A total of 83 AmpC-inducible Enterobacteriaceae were included in this study (58 clinical isolates with presumptive ESBL production and 25 molecularly characterized ESBL-producing isolates). Each isolate was tested for the presence of an ESBL enzyme by four phenotypic ESBL confirmation assays: ESBL Etests and combined double-disk synergy tests (CDDST), both on Mueller-Hinton (MH) agar with and without the use of cloxacillin, an AmpC inhibitor. Our study showed that performing a CDDST on MH agar with cefotaxime as the only indicator cephalosporin is not a reliable way to detect ESBL-encoding genes among chromosomal AmpC-producing Enterobacteriaceae due to its low sensitivity (52 %). The use of cloxacillin in this CDDST could only significantly increase the specificity of the CDDST when used with ceftazidime as the indicator [sensitivity (SN), 92 %; specificity (SP), 93 %]. Regarding ESBL Etest® strips, the sensitivity of the cefepime strip (80 %) was significantly higher compared to the cefotaxime and ceftazidime strips (16 % and 32 %, respectively). Adding cloxacillin to the MH agar improved the ESBL detection of each of these strips. We recommend the CDDST on MH agar supplemented with cloxacillin and ceftazidime or cefepime as the indicator cephalosporin as the most cost-efficient strategy to confirm ESBL production in inducible AmpC-producing Enterobacteriaceae.

Coxsackievirus B1 peritonitis in a patient treated with continuous ambulatory peritoneal dialysis: a case report and brief review of the literature.

We report a case of viral peritonitis caused by coxsackievirus B1 in a 79-year-old male undergoing continuous ambulatory peritoneal dialysis (CAPD), and review the English language literature. Clinicians should be aware of viral peritonitis in patients on CAPD presenting with a viral syndrome and mononuclear peritoneal dialysis effluent. Currently, viral diagnostic tests are available to confirm the diagnosis and avoid unnecessary treatment with antibiotics.

Q fever across the Dutch border in Limburg province, Belgium.

Data from three different data sources were compiled to estimate the presence of Coxiella burnetii in the Belgian Limburg province for both humans and livestock. First, serological data of all samples sent to the Belgian reference centre (2003­2010) for human Q fever were analysed, showing evidence for an acute Q fever infection in 1­5% of the cases. Second, a multi-centre prospective survey was conducted in Limburg in 2010 to detect undiagnosed human cases; evidence for a recent infection with Coxiella burnetii was found in three out of 100 patients from which clinicians suspected a Mycoplasma pneumoniae infection. Third, we analyzed data from the Belgian livestock screening program (2009­2010) which consisted of investigating all reported abortions, sampling tank milk, and serological screening of cattle. The results suggest an endemicity in the Limburgian livestock which seems to be especially high in cattle.

Timely diagnosis of respiratory tract infections: evaluation of the performance of the Respifinder assay compared to the xTAG respiratory viral panel assay.

BACKGROUND: Respiratory tract infections are the most common cause of hospitalization in infants and young children and are typically caused by viral or, less commonly, bacterial pathogens. Existing non-molecular diagnostic methods have several drawbacks such as limited sensitivity, long turn-a-round time and limited number of pathogens that can be detected. OBJECTIVES: Nucleic acid amplification methods can increase sensitivity and enable the initiation of appropriate interventions without delay. Broad-spectrum detection and identification circumvent the use of individual diagnostic DNA or RNA based assays. At present, several commercial assays are available for broad-spectrum detection. STUDY DESIGN: We compared the performance of the xTAG Respiratory Viral Panel (RVP) (Luminex Molecular Diagnostics, Toronto, Canada) with that of the Respifinder (Pathofinder, Maastricht, Netherlands) for 9 external quality assurance (EQA) panels (QCMD, Scotland) consisting of a total of 106 EQA samples. RESULTS: Both the RVP and the Respifinder assay have an excellent specificity. Sensitivity was 33% and 78% for the RVP and the Respifinder assay, respectively. For both assays, sensitivity was low for weak positive samples. DISCUSSION: The results of our study seem to indicate a better sensitivity for the Respifinder. Analysis of patient samples is necessary to evaluate the clinical performance.

Invasive fungal infection in an elderly patient with defective inflammatory macrophage function.

Macrophages are known to be involved in pathogen recognition and mediate host immune responses, but, in the clinical setting, their purported central role in opportunistic fungal infections has not been demonstrated to date. Herein, we describe a patient with invasive testicular aspergillosis in whom we found, for the first time, a defect in macrophage function.

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.

10th survey of antimicrobial resistance in noninvasive clinical isolates of Streptococcus pneumoniae collected in Belgium during winter 2007-2008.

OBJECTIVES: The aim of the study was to evaluate the antibiotic resistance in noninvasive clinical isolates of Streptococcus pneumoniae collected in Belgium during winter 2008-2007. METHOD: Four hundred and forty eight unduplicated isolates collected by 15 laboratories were tested by microdilution following CLSI. RESULTS: Insusceptibility rates (I+R) were as follows: penicillin G (PEN) 11.6% (4.0% R), ampicillin 11.4% (4.0% R), amoxicillin+/-clavulanic acid 0, cefaclor 10.3% (9.6% R), cefuroxime 9.2% (8.7% R), cefuroxime-axetil 8.7% (7.8% R), cefotaxime, ceftazidime and cefepime 2.0% (0% R), imipenem 2.5% (0% R), ciprofloxacin and ofloxacin 5.1% (0.4% R), levofloxacin 0.7% (0.4% R), moxifloxacin 0.4% (0.2% R), erythromycin (ERY) 29.7% (29.2% R), azithromycin 29.7% (28.8% R), telithromycin 0%, clindamycin 26.3% (25.4% R) and tetracycline (TET) 21.9% (16.5% R). From 2001 to 2008, a significant decrease in penicillin-insusceptibility (21.0% to 11.6%), penicillin-resistance (9.7% to 4.0%) and ciprofloxacin-insusceptibility (11.2% to 5.1%) was found. Cross-resistance between penicillin and other betalactams in penicillin-insusceptible isolates was incomplete: all these isolates remained fully susceptible to amoxicillin. Erythromycin-insusceptibility was significantly higher in children than in adults (43.9%/27.4%), while penicillin-insusceptibility significantly higher in Brussels than in the Flanders (22.9%/8.1%). The commonest resistance phenotype was ERY-TET (12.7%) followed by ERY (7.4%) and PEN-ERY-TET (5.8%). Capsular types 19 (25%), 14 (19.3%), 23 (15.4%) and 15 (13.5%) were the most important in penicillin-insusceptible. CONCLUSION: We noted a decrease in resistance to the majority of the compounds. Insusceptibility rates were higher in children than in adults and the difference between the north and the south of Belgium became less marked.

False-positive results by the platelia Aspergillus galactomannan antigen test for patients treated with amoxicillin-clavulanate.

The Aspergillus galactomannan test is a valuable tool in the diagnosis of invasive aspergillosis. We hereby report a high rate of false-positive results by the Platelia Aspergillus galactomannan antigen test (Bio-Rad Laboratories) for patients treated with amoxicillin-clavulanate.

Surveillance of antibiotic resistance in non invasive clinical isolates of Streptococcus pneumoniae collected in Belgium during winters 2003 and 2004.

A total of 391 and 424 non-invasive isolates of Streptococcus pneumoniae collected by 15 laboratories during the 2003 and 2004 survey were tested for their susceptibility by a microdilution technique following NCCLS recommendations. Insusceptibility rates (IR) in the two surveys (2003/2004) were as follows: penicillin 15.0/14.7% [8.4/6.4% Resistance (R)], ampicillin 17.4/14.6% (R 9.0/7.1%), amoxicillin +/- clavulanic acid 2.6/1.2 % (R 0/0%), cefaclor 14.3/14.1% (R 11.5/13.4%), cefuroxime 13.6/12.7% (R 10.5/11.8%), cefuroxime-axetil 10.5/11.8% (R 10.0/9.2%) (breakpoints based on 250 mg), cefotaxime 4.9/6.2% (R 1.3/2.4%), ceftazidime NotTested (NT)/6.4 (R NT/2.6%), cefepime NT/6.4 (R NT/2.6%), imipenem 7.7/8.9 % (R 1.8/1.4%), ertapenem 0.8/NT% (R O/NT%), ciprofloxacin 13.8/9.0% (R 4.3/2.4%), levofloxacin 3.3/2.8% (R 1.5/0.2%), moxifloxacin 0.6/0.2% (R 0.3/0%), ofloxacin 13.5/9.0% (R 4.3/2.4%), erythromycin 26.1/24.7% (R 25.3/24.5%), azithromycin 25.4/24.7% (R 24.6/24.5%), telithromycin 0.8/0.2% (R 0.5/0%), clindamycin 21.2/18.4% (R 19.2/17.7%) and tetracycline 32.3/22.1% (R 29.2/19.3%). There were only minor differences in resistance rates according to age, sample site, admission type (i.e. ambulatory, hospitalized or long-term care facility patients), gender and geographic origin. Overall, telithromycin (MIC50, MIC90 in 2003/2004: 0.015 microg/ml, 0.12 microg/ml/ 0.008,0.06 respectively), ertapenem (0.03; 0.25/NT), moxifloxacin (0.06; 0.25/0.06, 0.12), and amoxicillin +/- clavulanic acid (0.03; 0.25/0.015, 0.5) were the most active compounds in both surveys. In 2003, the most common resistance phenotype was isolated insusceptibility to tetracycline (10.5%) followed by combined insusceptibility to erythromycin and tetracycline (9.3%). Erythromycin-tetracycline resistance (10.4%) was the most common in 2004. Isolates showing resistance to an antibiotic were significantly more present in 2003 than in 2004 (50.4% versus 40.8%). In penicillin-insusceptible isolates, MICs of all beta-lactams were increased but cross-resistance between penicillin and other beta-lactams in the penicillin-insusceptible isolates was not complete. In the 2003 survey, most of these isolates remained fully susceptible to ertapenem (94.9%) and amoxicillin +/- clavulanic acid (83.1%). In the 2004 survey, 91.9% of the penicillin insusceptible isolates remained susceptible to amoxicillin +/- clavulanic acid. In both surveys, the most common serotypes in penicillin insusceptible isolates were 14, 23,19 and 9 (20.0%, 20.0%, 16.4% and 10.9% respectively in 2003; 41.6%, 11.7%, 15.0% and 18.3% respectively in 2004).

Recurrent Rhodococcus equi infection with fatal outcome in an immunocompetent patient.

The majority of human Rhodococcus equi infections occur in immunocompromised hosts, especially those with AIDS, and infection in immunocompetent patients is rare. Reported here is a case of R. equi infection in a seemingly healthy patient with a very complicated course. Despite neurosurgery and prolonged antibiotic therapy the patient deceased.