Findings from an outbreak of carbapenem-resistant Klebsiella pneumoniae emphasize the role of antibiotic treatment for cross transmission.

PURPOSE: In January 2015, we noticed by rectal swab analyses that seven of 23 patients at an early rehabilitation ward had been colonized with carbapenem-resistant Klebsiella pneumoniae (CKP). Here, we describe risk factors for CKP acquisition. METHODS: In the present study, the outbreak is described and risk factors for CKP acquisition are examined, e.g., antibiotic treatment. Microbiological analyses including corresponding results were examined to study when colonization with CKP occurred and whether patients had suffered from diarrhea. To examine whether spread of bacteria was clonal, multi-locus sequence typing as well as Xbal macrorestriction and pulsed-field gel electrophoresis was performed. The presence of carbapenmase was examined by PCR analysis. Through univariate analysis of risk factors in the small study sample, the role of antibiotic consumption, isolation procedures, patient's age, gender, and Barthel index on colonization was elucidated. RESULTS: Clonal spread of the novel sequence type (ST)2255 was identified. Additionally, one patient was colonized with Escherichia coli and Serratia marcescens, both resistant to carbapenems, while a further patient carried another carbapenem-resistant E. coli strain. In all isolates, carbapenemase gene bla OXA-48 was found to be located on a conjugative plasmid (60 kb), suggesting in vivo transmission from CKP to E. coli and S. marcescens. Univariate tests indicated that antibiotic treatment was the only risk factor showing a significant association with being colonized by CKP. In addition, the likelihood of diarrhea appeared to be higher in this group. Antibiotic treatment was associated with CKP colonization, whereas patients´ age, gender, Barthel index at admission, and residence with a CKP-colonized roommate were not. Diarrhea also seemed to support to distribution of CKP. CONCLUSIONS: In this small outbreak, antibiotic treatment seemed to be the predominant risk factor for monoclonal transmission of bla OXA-48 positive CKP.

"Blind periods" in screening for toxoplasmosis in pregnancy in Austria - a debate.

Recent studies from Austria, France and Italy have shown that there is a poor adherence to the screening scheme for maternal Toxoplasma infections in pregnancy demonstrated by the fact that many recommended examinations are missed. This leads to undetected infections and limits our knowledge of incidence of the disease. We discuss the negative consequences of this situation on research on treatment effectiveness and the outcomes of congenital toxoplasmosis. The responsible public health institutions should assume responsibility for appropriate surveillance of the screening programme and take measures to improve screening adherence during pregnancy. Screening should start as early as possible in pregnancy and the latest test should be done at delivery. Screening schedule should allow distinguishing infections from the first, second and third trimester of pregnancy, as the risk of materno-foetal transmission and outcomes in case of foetal infections varies by time.

The bacterial pathogen and resistance spectrum in a dermatological inpatient ward: a six-year, retrospective, epidemiological study.

Aim: Treatment of bacterial soft tissue infections is an essential part of clinical dermatology, and the choice of antibiotic therapy is often empirical. The aim of this longitudinal retrospective study was to evaluate bacterial epidemiology, resistance patterns and antibiotic consumption in a dermatological inpatient ward. Method: Bacterial isolates and antimicrobial susceptibility testing from a dermatological inpatient ward were recorded retrospectively from 2011 to 2016. The antibiotic consumption was evaluated and given as the assumed defined daily dose [DDD] per 100 days of covering per year. Results: A total of 4,800 bacterial isolates were included (skin, mucous membrane and wounds 87%, urine 9.5%, blood 1.7%, tissue and tissue fluids 1.6%). The proportion of Gram-positive bacteria was 58% (Staphy loc occus aureus 37.8%, coagulase-negative staphylococci 21.5%, Enterococcus spp. 16.7%). Pseudomonas aeruginosa (27.2%), Escherichia coli (17.5%) and Proteus spp. (13.1%) were the most common Gram-negative bacteria. The proportion of multi-resistant pathogens was 5.8% for methicillin-resistant S. aureus, 0.9%, 0.8% and 1.8% for multi-resis tant P. aeruginosa, ESBL-producing E. coli and ESBL-producing Klebsiella pneumoniae of all isolates. Beta-lactam antibiotics were the most used drugs (14.4, 10.8, and 9.6 DDD/100 for aminopenicillins, cefalexin, and penicillin G), followed by clindamycin (9.0 DDD/100 patient days). Conclusion: In view of the frequency of bacterial soft tissue infections and their need for inpatient treatment with mostly empirically chosen antibiotics, systematic microbiological surveillance should be recommended for dermatological inpatient wards.

Incidence of maternal Toxoplasma infections in pregnancy in Upper Austria, 2000-2007.

BACKGROUND: Despite three decades of prenatal screening program for toxoplasmosis in Austria, population-based estimates for the incidence of maternal infections with Toxoplasma gondii during pregnancy are lacking. We studied the incidence of primary maternal infections during pregnancy in the Federal State of Upper Austria. METHODS: Screening tests for 63,416 women and over 90,000 pregnancies (more than 84.5% of pregnancies in the studied region) in the time period between 01.01.2000 and 31.12.2007 were analysed. The incidence of toxoplasmosis was estimated indirectly by binomial and directly by interval censored regression. RESULTS: During the studied period, 66 acute infections (risk of 0.07% per pregnancy) were detected, but only 29.8% of seronegative women were tested at least three times during their pregnancies. The seroprevalence of Toxoplasma antibodies among all tested women was 31%. Indirectly estimated incidence (from differences in prevalence by age) was 0.5% per pregnancy, while directly estimated incidence (interval censored regression) was 0.17% per pregnancy (95% confidence interval: 0.13-0.21%). CONCLUSIONS: Calculating incidence from observed infections results in severe underreporting due to many missed tests and potential diagnostic problems. Using statistical modelling, we estimated primary toxoplasmosis to occur in 0.17% (0.13-0.21%) of all pregnancies in Upper Austria.

Prescriptions of broad-spectrum antibiotics to outpatients do not match increased prevalence and antibiotic resistance of respiratory pathogens in Bavaria.

In this study we present an analysis of prescription numbers of various antibiotic classes to Bavarian (Southern Germany) outpatients between 2000 and 2006 compared to fluctuating resistance patterns in representative respiratory pathogens. Prescriptions of "narrow-spectrum" antibiotics (e.g. penicillins, macrolides) decreased by 39% while prescriptions of "broad-spectrum" antibiotics increased by 38%. The most prominent increase was for quinolones and cephalosporines class II. Prescriptions of these antibiotics exhibited prominent seasonal alterations suggesting that these drugs had been used for treatment of respiratory infections. In contrast, the numbers of S. pneumoniae and H. influenzae detected in respiratory specimen decreased. Almost constant resistance rates of S. pneumoniae for first line antibiotics do not justify an increased use of cephalosporins class II and quinolones. Compared to Europe and Germany in general, consumption of antibiotics is low in Bavaria. Even at this low level we propose an education of physicians treating outpatients in a way to avoid an excessive use of antimicrobials.

Ciprofloxacin treatment of urinary infections results in increased resistance of urinary E. coli to ciprofloxacin and co-trimoxazole.

Between 2000 and 2006 the sum of ciprofloxacin and folic acid antagonists prescriptions to Bavarian (South-eastern Gemany) outpatients stayed constant. However, prescription numbers of ciprofloxacin increased while those of folic acid antagonists decreased suggesting an apparent shift in the treatment of urinary infections toward ciprofloxacin. During the observation period the proportion of E. coli resistant against ciprofloxacin increased from 5% to 10% while that against co-trimoxazole increased from 21% to 27%. The proportion of E. coli simultaneously exhibiting resistance to ciprofloxacin and co-trimoxazole increased from 3.9% to 8.5%. A leading influence of ciprofloxacin application for these developments is discussed.

Chronic Paracoccidioidomycosis with adrenal involvement mimicking tuberculosis - A case report from Austria.

Paracoccidioidomycosis is a systemic fungal infection caused by Paracoccidioides brasiliensis and endemic in certain areas of Central and South America. We report a case of a 62-year-old-man with a complex history of tuberculosis and imaging findings of a cerebral lesion and bilateral adrenal enlargement. Biopsy of adrenal gland revealed Paracoccidioides brasiliensis. This case highlights the importance of travel history for diagnosis of paracoccidioidomycosis in non-endemic areas and emphasizes the clinical and histopathological similarities with tuberculosis.

Long term monitoring of three automated HIV 4th generation combined antibody/antigen screening assays.

In a diagnostic laboratory performing analyses for about 40 hospitals and 2,000 physicians treating outpatients results of HIV 4th generation combined antibody/antigen screening assays were monitored over a period of 50 months. In period A (Jan 2007 - Mar 2009) 37,986 serum samples were examined by Architect and in period B (Apr 2009 - Feb 2011) 38,178 samples by Modular system. In period B1 (Apr 2009 - Jun 2010) 24,756 samples were analyzed only by Modular system while in period B2 (July 2010 - February 2011) 13,422 samples were examined in parallel by Modular and Axsym system. Sensitivity and negative predictive value of each was 100%. Specificities ranged from 99.69-99.88% and positive predictive values (ppv) from 35.1-65.9%. Architect test results obtained a better reliability than Modular test results while Axsym test results were similar to that of Architect system. However, specificity and ppv of Modular system was markedly improved in period B2. In summary our study shows that long term monitoring of HIV combined antibody/antigen screening test results allows discovering of impairment and improvement of HIV testing quality. We also show that in a low prevalence region specificities of > 99% are accompanied by relatively low ppv. Increase of cut off values to define reactivity of the tests will increase specificities and ppv without affecting sensitivity.

Rifaximin disc diffusion test for in vitro susceptibility testing of Clostridium difficile.

Rifaximin is a rifampicin derivative, poorly absorbed by the gastro-intestinal tract. We studied the in vitro susceptibility to rifamixin of 1082 Clostridium difficile isolates; among these, 184 isolates from a strain collection were tested by an in-house rifaximin disc (40 µg) diffusion test, by an in-house rifaximin broth microdilution test, by rifampicin Etest and by rpoB gene sequencing. In the absence of respective CLSI or EUCAST MIC breakpoints for rifaximin and rifampicin against C. difficile we chose MIC ≥32 µg ml(-1) as criterion for reduced in vitro susceptibility. To further validate the disc diffusion test 898 consecutive clinical isolates were analysed using the disc diffusion test, the Etest and rpoB gene sequence analysis for all resistant strains. Rifaximin broth microdilution tests of the 184 reference strains yielded rifaximin MICs ranging from 0.001 (n = 1) to ≥1024 µg ml(-1) (n = 61); 62 isolates showed a reduced susceptibility (MIC ≥32 µg ml(-1)). All of these 62 strains showed rpoB gene mutations producing amino acid substitutions; the rifampicin- and rifaximin-susceptible strains showed either a wild-type sequence or silent amino acid substitutions (19 strains). For 11 arbitrarily chosen isolates with rifaximin MICs of >1024 µg ml(-1), rifaximin end-point MICs were determined by broth dilution: 4096 µg ml(-1) (n = 2), 8192 µg ml(-1) (n = 6), 16,384 µg ml(-1) (n = 2) and 32,678 µg ml(-1) (n = 1). Rifampicin Etests on the 184 C. difficile reference strains yielded MICs ranging from ≤0.002 (n = 117) to ≥32 µg ml(-1) (n = 59). Using a 38 mm inhibition zone as breakpoint for reduced susceptibility the use of rifaximin disc diffusion yielded 59 results correlating with those obtained by use of rifaximin broth microdilution in 98.4 % of the 184 strains tested. Rifampicin Etests performed on the 898 clinical isolates revealed that 67 isolates had MICs of ≥32 µg ml(-1). There were no discordant results observed among these isolates with reduced susceptibility using an MIC of ≥32 µg ml(-1) as breakpoint for reduced rifampicin susceptibility and a <38 mm inhibition zone as breakpoint for reduced rifaximin susceptibility. The prevalence of reduced susceptibility was 7.5 % for all isolates tested. However, for PCR ribotype 027 the prevalence of reduced susceptibility was 26 %. Susceptibility testing in the microbiology laboratory therefore could have an impact on the care and outcome of patients with infection. Our results show that rifaximin--despite its water-insolubility--may be a suitable candidate for disc diffusion testing.

Rubella in Austria 2008-2009: no longer a typical childhood disease.

BACKGROUND: In February 2009, a cluster of rubella cases was recognized in Austria occurring between calendar weeks 3 and 7, 2009 after a long period of low rubella virus activity. A nationwide 2-dose measles, mumps, and rubella vaccination program had been introduced in 1994 to prevent this childhood illness. METHODS: An epidemiologic investigation was conducted to describe the cluster by time, place, and person. A confirmed outbreak case was defined as a febrile person (1) with generalized rash, which was laboratory confirmed or epidemiologically linked to a laboratory confirmed case and (2) who became ill after October 1, 2008 in the 2 affected provinces. A probable outbreak case was defined as any person meeting the clinical criteria of rubella and meeting the criterion 2 of a confirmed outbreak case. All cases were telephone interviewed on demographics and vaccination status. RESULTS: A total of 355 outbreak cases (including 247 confirmed cases) occurred in 2 neighboring Austrian provinces from mid-October 2008 until the end of June 2009, peaking in mid-March. The 2 most-affected age groups were 15 to 19 (44.4%) and 20 to 24 year olds (32.4%). The vaccination status was available for 230 cases; 10% of cases had received 1 measles, mumps, and rubella vaccine dose. No case had received 2 doses. Of the 146 female cases, one laboratory-confirmed rubella infection in a pregnant 18-year-old native Austrian resulted in elective abortion. CONCLUSIONS: These findings underline the waning epidemiologic role of children in maintaining the circulation of rubella virus and indicate that additional vaccination activities targeting >15 year olds are needed to achieve the 2010 WHO target for rubella elimination in the European Region.

Mixture model to assess the extent of cross-transmission of multidrug-resistant pathogens in hospitals.

OBJECTIVE: Creation of a mixture model based on Poisson processes for assessment of the extent of cross-transmission of multidrug-resistant pathogens in the hospital. METHODS: We propose a 2-component mixture of Poisson processes to describe the time series of detected cases of colonization. The first component describes the admission process of patients with colonization, and the second describes the cross-transmission. The data set used to illustrate the method consists of the routinely collected records for methicillin-resistant Staphylococcus aureus (MRSA), imipenem-resistant Pseudomonas aeruginosa, and multidrug-resistant Acinetobacter baumannii over a period of 3 years in a German tertiary care hospital. RESULTS: For MRSA and multidrug-resistant A. baumannii, cross-transmission was estimated to be responsible for more than 80% of cases; for imipenem-resistant P. aeruginosa, cross-transmission was estimated to be responsible for 59% of cases. For new cases observed within a window of less than 28 days for MRSA and multidrug-resistant A. baumannii or 40 days for imipenem-resistant P. aeruginosa, there was a 50% or greater probability that the cause was cross-transmission. CONCLUSIONS: The proposed method offers a solution to assessing of the extent of cross-transmission, which can be of clinical use. The method can be applied using freely available software (the package FlexMix in R) and it requires relatively little data.

Evaluation of the Abbott ARCHITECT Toxo IgM assay.

Development of the ARCHITECT Toxo IgM assay has been done to assist the clinician in acute Toxoplasma gondii infection detection, especially in pregnant women. Its use, in conjunction with ARCHITECT Toxo IgG and Toxo Avidity assays, will provide an array of assays particularly useful in the monitoring of pregnant females to determine the risk of maternal transmission of the parasite. Specificity results from 2 testing sites, using populations of pregnant females, hospital patients, and blood donors, demonstrated that the assay has an overall resolved relative specificity of 99.89% (confidence interval, 99.68-99.98%). Relative specificity for pregnant female specimens was 99.95% (n = 2031). Excellent seroconversion sensitivity was observed for the ARCHITECT Toxo IgM assay, which was similar to the Abbott AxSYM Toxo IgM assay (Abbott Laboratories, Abbott Park, IL). In more than 90% of the panels tested, the 1st bleed detected in the serial bleeds was the same for both assays.

Vancomycin-resistant enterococci outbreak, Germany, and calculation of outbreak start.

On the basis of a large outbreak of vancomycin-resistant Enterococcus faecium in a German university hospital, we estimated costs ( approximately 1 million Euros) that could have been avoided by early detection of the imminent outbreak. For this purpose, we demonstrate an easy-to-use statistical method.