Infection risks of city canal swimming events in the Netherlands in 2016.

INTRODUCTION: Swimming events in city canals are gaining popularity in the Netherlands, even though canal water is usually not officially designated for recreational use. Knowledge regarding the risk of infection after swimming in canals is limited. An outbreak was reported in 2015 following a canal swimming event in Utrecht, the Netherlands. Local governments were concerned about the health risks of such events. In order to assess the safety of canal swimming, the Public Health Service (PHS) prospectively investigated two city canal swimming events in 2015. In 2016, we repeated this study, aiming to prospectively determine the risks of infection during two urban swimming events, the Utrecht SingelSwim 2016 (USS) and the Amsterdam City Swim 2016 (ACS). METHODS: We sent online questionnaires to 271 USS participants and 2697 ACS participants, concerning personal characteristics, symptoms, and exposure. Participants were asked to forward the questionnaire to three relatives, i.e., non-exposed. We analyzed water samples from the USS venue taken during the event, as well as stool samples of USS participants with acute gastrointestinal illness (AGI). AGI was defined as diarrhea and/or vomiting within seven days after the event. We calculated adjusted risk ratios (RR) for AGI in the exposed group compared with non-exposed respondents, using binomial regression models. RESULTS: The questionnaire was returned by 160 USS participants (exposed) (59%) and 40 non-exposed relatives. Five percent of the exposed (n = 17) and 3% of non-exposed (n = 1) reported AGI (RR = 1.69; 95% CI: 0.23-12.46). Norovirus genogroup II was detected in two of six USS water samples and in none of the three stool samples. In one of three stool samples, rotavirus was detected. The questionnaire was returned by 1169 ACS participants (exposed) (43%) and 410 non-exposed relatives. Six percent of the exposed (n = 71) and 1% of non-exposed (n = 5) reported AGI (RR 4.86; 95% CI: 1.98-11.97). CONCLUSION: Results of the ACS event showed a higher risk for AGI among the exposed, indicating that participants of events in urban canals in the Netherlands could be at a higher risk for AGI than those not participating. The inconclusive results from the USS are likely due to the small sample size. Swimming in non-monitored open water can bring health risks and more knowledge about environmental and human risk factors helps reduce the risk by being able to more specifically advise organizations and governments.

Gram-positive cocci in Dutch ICUs with and without selective decontamination of the oropharyngeal and digestive tract: a retrospective database analysis.

OBJECTIVES: The objective of this study was to determine time trends in the rate of Gram-positive cocci in 42 Dutch ICUs that continuously used or did not use selective oropharyngeal decontamination (SOD) or selective decontamination of the digestive tract (SDD) and ICUs that introduced SOD/SDD. METHODS: The Dutch Surveillance System on Antibiotic Resistance was used to determine monthly rates of Staphylococcus aureus, Enterococcus faecalis and Enterococcus faecium isolates, including resistant phenotypes, in blood and respiratory tract specimens from 2008 to 2013. Per patient, the last isolate per species per month was selected, and cumulative rates per 100 beds per month were determined. Time trends were analysed by multilevel Poisson regression. RESULTS: Eighteen ICUs used SOD/SDD (1296 months), 13 did not use SOD/SDD (936 months) and 11 introduced SOD/SDD (373 months before and 419 months after introduction). There was no significant increase in the rate of Gram-positive cocci in ICUs that used SOD/SDD. Introduction of SOD/SDD was associated with increased rates of S. aureus (ß = 0.018, 95% CI 0.006-0.030) and E. faecalis isolates (ß = 0.028, 95% CI 0.006-0.051) in respiratory tract specimens. Numbers of resistant phenotypes remained low, and an observed increase in E. faecium isolates (ß = 0.033, 95% CI 0.012-0.054), 97% of which were resistant to ampicillin, in the absence of SOD/SDD disappeared after the introduction of SOD/SDD. CONCLUSIONS: In ICUs with a low endemicity of resistance, introduction of SOD/SDD was associated with increased rates of S. aureus and E. faecalis isolates, but not with resistant phenotypes. Continuous 5 year use of SOD/SDD was not associated with increased isolation of Gram-positive cocci.

Selective decontamination of the oropharynx and the digestive tract, and antimicrobial resistance: a 4 year ecological study in 38 intensive care units in the Netherlands.

OBJECTIVES: Selective oropharyngeal decontamination (SOD) and selective decontamination of the digestive tract (SDD) are associated with improved outcomes among patients in intensive care units (ICUs), but uncertainty remains about their long-term effects on resistance levels. We determined trends in antibiotic resistance among Gram-negative bacteria in 38 Dutch ICUs using and not using SOD/SDD. METHODS: The Infectious Disease Surveillance Information System-Antibiotic Resistance (ISIS-AR) was used to identify all Enterobacteriaceae, Pseudomonas aeruginosa and Acinetobacter spp. isolates from blood and respiratory tract specimens from ICUs between January 2008 and April 2012. Per patient, the last isolate per species per specimen per month was selected to determine cumulative resistance rates (per 100 beds/month) for colistin, tobramycin, ciprofloxacin, ceftazidime and cefotaxime/ceftriaxone in ICUs that continuously used or did not use SOD/SDD, and ICUs that introduced SOD/SDD. Time trends were analysed by multilevel Poisson regression. RESULTS: Seventeen ICUs continuously used SOD/SDD (859 months), 13 did not use SOD/SDD (663 months) and 8 introduced SOD/SDD (223 and 117 months before and after introduction). There were no discernible trends in antibiotic resistance among 637 blood isolates. For the 8353 respiratory isolates, resistance to cefotaxime/ceftriaxone increased in ICUs that did not use SOD/SDD (P < 0.001) and decreased in those that continuously used SOD/SDD (P = 0.04), as did resistance to ciprofloxacin (P < 0.001). The introduction of SOD/SDD was followed by statistically significant reductions in resistance rates for all antimicrobial agents. CONCLUSIONS: Continuous use of SOD/SDD was associated with decreasing trends for resistance to cefotaxime/ceftriaxone and ciprofloxacin. The introduction of SOD/SDD was associated with reductions in resistance rates for all antimicrobial agents included.

Clinical breakpoint changes and their impact on surveillance of antimicrobial resistance in Escherichia coli causing bacteraemia.

Dutch laboratories are currently changing their breakpoint criteria from mostly Clinical Laboratory and Standards Institute (CLSI) breakpoints to European Committee on Antimicrobial Susceptibility Testing (EUCAST) breakpoints. To evaluate the impact of these changes, we studied antimicrobial resistance trends of Escherichia coli in blood specimens from January 2008 to January 2012 using CLSI and EUCAST breakpoints and compared them with the antimicrobial susceptibility test (AST) interpretations reported by Dutch laboratories participating in the Infectious Disease Surveillance Information System for Antibiotic Resistance (ISIS-AR). ISIS-AR collects AST interpretations, including underlying minimal inhibitory concentrations (MICs) of routinely cultured bacterial species on a monthly basis from Dutch laboratories. MICs of Etests or automated systems were reinterpreted according to the CLSI 2009 and EUCAST 2010 guidelines. Trends in non-susceptibility (i.e. intermediate resistant and resistant) over time were analysed by the Cochran-Armitage test for trend. The effects of the change from CLSI to EUCAST breakpoints on non-susceptibility were small. There were no differences in non-susceptibility to amoxicillin, amoxicillin/clavulanic acid, cefuroxim, gentamicin and co-trimoxazol and only small differences (1-1.5%) for ciprofloxacin between AST interpretations by CLSI or EUCAST. However, for ceftazidime, and cefotaxime/ceftriaxone the proportion of non-susceptibility was substantially higher when EUCAST breakpoints were used (2-3%). The effects on time trends of the change in guidelines were limited, with only substantial differences for the oxymino-cephalosporins. Our study shows that the implementation of EUCAST breakpoints has a limited effect on the proportion of non-susceptible isolates and time trends in E. coli for most, but not all, antimicrobial agents.

Metallo-ß-lactamase-producing Pseudomonas aeruginosa in the Netherlands: the nationwide emergence of a single sequence type.

Recently, the first outbreak of clonally related VIM-2 metallo-ß-lactamase (MBL)-producing Pseudomonas aeruginosa in a Dutch tertiary-care centre was described. Subsequently, a nationwide surveillance study was performed in 2010-2011, which identified the presence of VIM-2 MBL-producing P. aeruginosa in 11 different hospitals. Genotyping by multiple-locus variable-number tandem-repeat analysis (MLVA) showed that the majority of the 82 MBL-producing isolates found belonged to a single MLVA type (n = 70, 85%), identified as ST111 by multilocus sequence typing (MLST). As MBL-producing isolates cause serious infections that are difficult to treat, the presence of clonally related isolates in various hospitals throughout the Netherlands is of nationwide concern.

First outbreak of VIM-2 metallo-ß-lactamase-producing Pseudomonas aeruginosa in The Netherlands: microbiology, epidemiology and clinical outcomes.

This study was designed to investigate the prevalence and characteristics of metallo-ß-lactamase (MBL)-producing Pseudomonas aeruginosa in a tertiary care centre in The Netherlands, a country that is considered to have a low prevalence of antibiotic-resistant bacteria. Imipenem-resistant P. aeruginosa isolates cultured from clinical specimens during 2008-2009 were analysed phenotypically and molecularly by polymerase chain reaction (PCR) with sequencing. Genotyping was performed by multiple-locus variable-number tandem repeat (VNTR) analysis (MLVA). Clinical information was obtained by electronic chart review for all patients infected or colonised with an imipenem-resistant P. aeruginosa isolate that was included in the study. In total, 106 imipenem-resistant P. aeruginosa isolates were included. The bla(VIM-2) gene was detected in 35/106 isolates (33%) and was associated with integrons. Compared with non-MBL-producing imipenem-resistant P. aeruginosa, VIM-2 MBL-producing isolates showed higher rates of multidrug resistance. Patients with VIM-2 MBL-producing isolates were more likely to be admitted to the Intensive Care Unit (ICU) and had a higher risk of invasive infection, including development of bacteraemia. MLVA identified two separate VIM-2 MBL-producing clones, responsible for outbreaks in the ICU but also affecting 10 other departments. This is the first reported outbreak of VIM-2 MBL-producing P. aeruginosa in The Netherlands. Once introduced, VIM-2 MBL-producing P. aeruginosa cause significant infections and are easily spread within the hospital setting.

Immediate incubation of blood cultures outside routine laboratory hours of operation accelerates antibiotic switching.

The aim of this prospective randomized controlled clinical trial was to assess the impact of immediate incubation of blood cultures delivered to the laboratory outside its hours of operation on turnaround times, antibiotic prescription practices, and patient outcomes. A continuously monitoring blood culture incubator was placed outside the laboratory, which was switched on (intervention arm) and off (control arm) in a randomized manner. Included were new bacteremia episodes of patients older than 18 years. During the 30-week study period, the first positive blood culture specimen of an episode had to be brought to the laboratory outside its hours of operation. The median time from specimen collection until growth detection was reduced by 10.1 h in the intervention arm (P < 0.001). For 46 of 66 (70%) episodes in the intervention arm and for 51 of 85 (60%) episodes in the control arm, the antibiotic regimen was changed (not significant). The median time until the first change in the antibiotic regimen was 42.8 h in the intervention arm and 64.0 h in the control arm (P, 0.024). There was no difference in length of stay or hospital mortality. Immediate incubation of blood cultures outside laboratory hours reduces turnaround times and accelerates antibiotic switching.

Needle-to-incubator transport time: logistic factors influencing transport time for blood culture specimens.

The maximum recommended transport time for blood cultures is 4 h [L. S. Garcia (ed.), 2007 Update: Clinical Microbiology Procedures Handbook, 2nd ed., 2007]. In a previous study, we found that the average transport time was 10 h. In this cohort study, we measured transport times for blood cultures in a larger sample and identified predictors for transport times. A total of 4,322 blood cultures from 1,313 patients were included. The median transport time was 3.5 h, with 47% of cultures exceeding the recommended 4 h. Off-site location and type of clinical specialty were the most important predictors of long transport times. Cultures collected during weekend days or on wards at the largest distances from the laboratory were also associated with long transport times.

Increase of sexually transmitted infections, but not HIV, among young homosexual men in Amsterdam: are STIs still reliable markers for HIV transmission?

OBJECTIVES: The incidence of HIV and STIs increased among men who have sex with men (MSM) visiting our STI clinic in Amsterdam. Interestingly, HIV increased mainly among older (> or =35 years) MSM, whereas infection rates of rectal gonorrhoea increased mainly in younger men. To explore this discrepancy we compared trends in STIs and HIV in a cohort of young HIV negative homosexual men from 1984 until 2002. METHODS: The study population included 863 men enrolled at < or =30 years of age from 1984 onward in the Amsterdam Cohort Studies (ACS). They had attended at least one of the 6 monthly follow up ACS visits at which they completed a questionnaire (including self reported gonorrhoea and syphilis episodes) and were tested for syphilis and HIV. Yearly trends in HIV and STI incidence and risk factors were analysed using Poisson regression. RESULTS: Mean age at enrollment was 25 years. The median follow up time was 4 years. Until 1995 trends in HIV and STI incidence were concurrent, however since 1995 there was a significant (p<0.05) increase in syphilis (0 to 1.4/100 person years (PY)) and gonorrhoea incidence (1.1 to 6.0/100 PY), but no change in HIV incidence (1.1 and 1.3/100 PY). CONCLUSIONS: The incidence of syphilis and gonorrhoea has increased among young homosexual men since 1995, while HIV incidence has remained stable. Increasing STI incidence underscores the potential for HIV spread among young homosexual men. However, several years of increasing STIs without HIV, makes the relation between STI incidence and HIV transmission a subject for debate.

[Less refusal to participate in HIV screening among pregnant women in the Amsterdam region since the introduction of standard HIV screening using the opting-out method]. / Minder weigering van deelname aan HIV-screening door zwangeren in Amsterdam sedert de invoering van de standaard-HIV-screening--tenzij weigering ('opting-out'-methode).

In 2003 the Municipal Health Service in Amsterdam started to screen pregnant women for HIV according to the opting-out method. In this method the HIV test is routinely included in the prenatal screening along with hepatitis B virus (HBV) and syphilis. If the woman does not want to be tested for HIV then she must actively opt out of this test. This screening method was chosen because in the universal screening method used in 2002, women had to give their explicit consent to test for HIV and this led to a high refusal rate (13.6%), especially among women from AIDS-endemic countries. After the introduction of the opting-out method, the refusal rate fell from 3% in the first quarter of 2003 to 1.4% in the last quarter of 2003. None of the women refused to be tested for HBV or syphilis. In 2003, the HIV prevalence among pregnant women was 0.3% (35/13.621). The experiences with this screening method in Amsterdam were used to implement the national opting-out method for HIV screening in pregnant women, which was introduced on 1 January 2004.

Physical activity and older adults: a review of health benefits and the effectiveness of interventions.

The purpose of this multidisciplinary review paper is to critically review evidence from descriptive, efficacy and effectiveness studies concerned with physical activity and older people. Both levels of fitness (aerobic power, strength, flexibility and functional capability) and measures of physical activity involvement decline with age, and the extent to which this is due to a biological ageing processes or disuse (physical inactivity) is critically examined. The review will consider the evidence for a causal relationship between sedentary behaviour/physical activity programmes and cardiovascular, musculoskeletal and psycho-social health, independent living and health-related quality of life into old age. The review also considers the effectiveness of different physical activity interventions for older people and issues relating to cost-effectiveness. The implications for future policy in terms of research, health care services, and education and training are briefly discussed.

[HIV-screening among pregnant women in the region of Amsterdam in 2002]. / HIV-screening onder zwangere vrouwen in de regio Amsterdam in 2002.

In 2001, the Municipal Health Service started offering HIV tests to all pregnant women in and around Amsterdam. All midwives and all hospitals but one participated in this HIV screening. In 2002, of the 10,752 pregnant women offered HIV testing 13.6% refused. HIV antibodies were detected in 24 women (0.26%). The HIV prevalence was doubled compared to the prevalence in 1990-1991, but the number of newly HIV-infected pregnant women remained stable (0.1%). The high number of refusals, as a result of which many HIV-infected women might be missed, is alarming. For this reason, in January 2003, the Municipal Health Service started HIV testing by the opting-out approach. Under the opting-out approach, women are notified that an HIV test will be included in the standard test battery, together with tests for hepatitis B and syphilis, unless she explicitly refuses. It is expected that the opting-out approach for HIV screening of pregnant women will be implemented nationwide in 2003.

Psychological impact of preconception counseling: assessment of anxiety before and during pregnancy.

OBJECTIVE: Assessment of anxiety levels in women and men before and after preconception counseling and during the first trimester of pregnancy. METHODS: Couples were recruited from the fertility clinic of the University Medical Center Nijmegen, the Netherlands. Anxiety was assessed using the 40-item Spielberger State-Trait Anxiety Inventory (STAI). RESULTS: 53 women and 51 men (74%) completed the STAI both before and after counseling. Anxiety levels did not change significantly after counseling or during the first trimester of pregnancy. 83.4% would recommend preconception counseling to others. CONCLUSION: Preconception counseling is valued by the majority of women and men and does not lead to adverse psychological effects.

Results of high-energy transurethral microwave thermotherapy in patients categorized according to the American Society of Anesthesiologists operative risk classification.

OBJECTIVES: To evaluate the relation between the American Society of Anesthesiologists (ASA) classification and response to transurethral microwave thermotherapy (TUMT) in patients with lower urinary tract symptoms and benign prostatic hyperplasia (BPH). METHODS: Two hundred forty-seven patients with symptomatic BPH treated with high-energy TUMT were scored retrospectively for ASA status. Student's t test was used to determine differences in improvement at each point of follow-up between patients classified as ASA 1 or 2 and patients classified as ASA 3 or 4. Logistic regression analysis was performed to assess the predictive value of ASA status for response using the World Health Organization response evaluation criteria for International Prostate Symptom Score, maximal flow rate, and urodynamic obstruction. RESULTS: There was a significant improvement in objective and subjective parameters at 12, 26, and 52 weeks of follow-up in both ASA 1 and 2 patients and ASA 3 and 4 patients. There was no difference in objective and subjective improvement between both groups at each point of follow-up. Objective and subjective improvement in ASA 3 and 4 patients with cardiovascular disease and ASA 3 and 4 patients with noncardiovascular disease was the same, although patients with cardiovascular disease received less energy during TUMT. Using logistic regression analysis, ASA classification was not predictive of response after high-energy TUMT. CONCLUSIONS: There is no relation between ASA classification and outcome after high-energy TUMT. Because these patients are considered at high risk of perioperative complications and postoperative morbidity, TUMT could contribute considerably to the treatment of BPH in this specific group of patients.