Antibiotic prescriptions in the context of suspected bacterial respiratory tract superinfections in the COVID-19 era: a retrospective quantitative analysis of antibiotic consumption and identification of antibiotic prescription drivers

This study aims to quantify antibiotic consumption for suspected respiratory tract superinfections in COVID-19 patients, while investigating the associated drivers of antibiotic prescribing in light of the current signs of antibiotic overuse. Adult patients with a positive COVID-19 diagnosis admitted to a Belgian 721-bed university hospital were analyzed retrospectively (March 11th-May 4th, 2020), excluding short-term admissions (< 24 h). Antibiotic prescriptions were analyzed and quantified, using Defined Daily Doses (DDD) per admission and per 100 bed days. Possible drivers of antibiotic prescribing were identified by means of mixed effects logistic modelling analysis with backwards selection. Of all included admissions (n = 429), 39% (n = 171) were prescribed antibiotics for (presumed) respiratory tract superinfection (3.6 DDD/admission; 31.5 DDD/100 bed days). Consumption of beta-lactamase inhibitor-penicillin combinations was the highest (2.55 DDD/admission; 23.3 DDD/100 bed days). Four drivers were identified: fever on admission (OR 2.97; 95% CI 1.42-6.22), lower SpO₂/FiO₂ ratio on admission (OR 0.96; 95% CI 0.92-0.99), underlying pulmonary disease (OR 3.04; 95% CI 1.12-8.27) and longer hospital stay (OR 1.09; 95% CI 1.03-1.16). We present detailed quantitative antibiotic data for presumed respiratory tract superinfections in hospitalized COVID-19 patients. In addition to knowledge on antibiotic consumption, we hope antimicrobial stewardship programs will be able to use the drivers identified in this study to optimize their interventions in COVID-19 wards.

Haemolytic uremic syndrome surveillance in children less than 15 years in Belgium, 2009-2015

Background

The Haemolytic Uremic Syndrome (HUS) is the most severe manifestation of infection with Shiga toxin-producing Escherichia coli (STEC). In Belgium, the surveillance of paediatric HUS cases is conducted by a sentinel surveillance network of paediatricians called Pedisurv. In this article, we present the main findings of this surveillance from 2009 to 2015 and we describe an annual incidence of HUS.

Methods

For each case of HUS <  15 years notified by the paediatricians, clinical, microbiological and epidemiological data were collected by a questionnaire. National hospital discharge data with ICD-9 code 283.11 were used to calculate the incidence of HUS in children < 15 years.

Results

From 2009 to 2015, 110 cases were notified to the Pedisurv network with a mean annual notification rate of 0.8/100,000 in children < 15 years. Death occurred in 2.5% of all patients and the median number of days of hospitalization was 10 days. One third (35.4%) of the HUS cases were confirmed positive STEC, with a majority of STEC O157. The mean annual incidence based on the hospital discharge data was 3.2/100,000 in children < 15 years and 4.5/100,000 in children < 5 years.

Conclusion

The incidence of paediatric HUS in Belgium is high compared to other European countries. Its surveillance in Belgium is quite comprehensive and, although less effective than monitoring all STEC infections to detect the emergence of outbreaks, is important to better monitor circulation of the most pathogenic STEC strains. In this context, efforts are still needed to send samples and STEC strains from HUS cases to the National Reference Centre.

Transmission of HIV Drug Resistance and the Predicted Effect on Current First-line Regimens in Europe

Transmitted human immunodeficiency virus drug resistance in Europe is stable at around 8%. The impact of baseline mutation patterns on susceptibility to antiretroviral drugs should be addressed using clinical guidelines. The impact on baseline susceptibility is largest for nonnucleoside reverse transcriptase inhibitors.

Background. Numerous studies have shown that baseline drug resistance patterns may influence the outcome of antiretroviral therapy. Therefore, guidelines recommend drug resistance testing to guide the choice of initial regimen. In addition to optimizing individual patient management, these baseline resistance data enable transmitted drug resistance (TDR) to be surveyed for public health purposes. The SPREAD program systematically collects data to gain insight into TDR occurring in Europe since 2001.

Methods. Demographic, clinical, and virological data from 4140 antiretroviral-naive human immunodeficiency virus (HIV)–infected individuals from 26 countries who were newly diagnosed between 2008 and 2010 were analyzed. Evidence of TDR was defined using the WHO list for surveillance of drug resistance mutations. Prevalence of TDR was assessed over time by comparing the results to SPREAD data from 2002 to 2007. Baseline susceptibility to antiretroviral drugs was predicted using the Stanford HIVdb program version 7.0.

Results. The overall prevalence of TDR did not change significantly over time and was 8.3% (95% confidence interval, 7.2%–9.5%) in 2008–2010. The most frequent indicators of TDR were nucleoside reverse transcriptase inhibitor (NRTI) mutations (4.5%), followed by nonnucleoside reverse transcriptase inhibitor (NNRTI) mutations (2.9%) and protease inhibitor mutations (2.0%). Baseline mutations were most predictive of reduced susceptibility to initial NNRTI-based regimens: 4.5% and 6.5% of patient isolates were predicted to have resistance to regimens containing efavirenz or rilpivirine, respectively, independent of current NRTI backbones.

Conclusions. Although TDR was highest for NRTIs, the impact of baseline drug resistance patterns on susceptibility was largest for NNRTIs. The prevalence of TDR assessed by epidemiological surveys does not clearly indicate to what degree susceptibility to different drug classes is affected.

Analysis of Bordetella pertussis clinical isolates circulating in European countries during the period 1998-2012

Despite more than 50 years of vaccination, pertussis is still an endemic disease, with regular epidemic outbreaks. With the exception of Poland, European countries have replaced whole-cell vaccines (WCVs) by acellular vaccines (ACVs) in the 1990s. Worldwide, antigenic divergence in vaccine antigens has been found between vaccine strains and circulating strains. In this work, 466 Bordetella pertussis isolates collected in the period 1998–2012 from 13 European countries were characterised by multi-locus antigen sequence typing (MAST) of the pertussis toxin promoter (ptxP) and of the genes coding for proteins used in the ACVs: pertussis toxin (Ptx), pertactin (Prn), type 2 fimbriae (Fim2) and type 3 fimbriae (Fim3). Isolates were further characterised by fimbrial serotyping, multi-locus variable-number tandem repeat analysis (MLVA) and pulsed-field gel electrophoresis (PFGE). The results showed a very similar B. pertussis population for 12 countries using ACVs, while Poland, which uses a WCV, was quite distinct, suggesting that ACVs and WCVs select for different B. pertussis populations. This study forms a baseline for future studies on the effect of vaccination programmes on B. pertussis populations.

[Hooping cough in adults, think about it!]

We report the case of a 47 year old patient who had been suffering from persistent cough for more than three weeks. Patient coughed predominantly during night time, without fever. The amoxicillin-clavulanic acid initially prescribed was not effective. A series of complementary investigations were performed before serology finally identified Bordetella pertussis infection after two months of symptoms which improved slowly without evident benefit of macrolide treatment. The diagnosis of whooping cough was also established for the wife of the patient with fast resolution of the symptoms after rapid unset of treatment with macrolides.

In vitro activity of temocillin against prevalent extended-spectrum beta-lactamases producing Enterobacteriaceae from Belgian intensive care units

Temocillin is a narrow spectrum penicillin with high stability to most beta-lactamases including AmpC types and extended-spectrum types (ESBLs). We have analysed its in vitro activity against 652 clinical isolates of Enterobacteriaceae prospectively collected from patients hospitalised in intensive care units at seven different university hospitals in Belgium in 2005. Strains were screened for ESBL production using cefotaxime and ceftazidime screen agar plates and by double ESBL E-tests. The MIC of temocillin and of five comparators was determined using the E-test method. ESBLs were characterized at one central laboratory by isoelectric focusing, PCR for bla genes of the SHV, TEM, and CTX-M families, and by DNA sequencing. The prevalence of ESBL-producing Enterobacteriaceae averaged 11.8% and ranged between 3.0 and 29% in the different hospitals. Meropenem exhibited the highest in vitro activity overall (mode MIC 0.064 microg; MIC(90); 0.19 microg/ml), whereas ceftazidime (MIC(90) > 256 microg/ml) and ciprofloxacin (MIC(90) > 32 microg/ml) scored the worst. Temocillin was active against more than 90% of the isolates including most AmpC- and ESBL-producing isolates. These data indicate the well preserved activity of temocillin over the years against Enterobacteriaceae and show the wide variation in prevalence of ESBL-producing Enterobacteriaceae isolates in Belgian intensive care units. Prospective clinical studies are, however, needed to validate the usefulness of temocillin in the treatment of microbiologically documented infections caused by ESBL- and/or AmpC- overproducing nosocomial Enterobacteriaceae pathogens.

National survey of molecular epidemiology of Staphylococcus aureus colonization in Belgian cystic fibrosis patients

OBJECTIVES

Epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) is poorly defined in cystic fibrosis (CF) patients, and S. aureus detection may be hampered by the presence of small colony variants (SCVs). We conducted a multicentre survey to determine the prevalence of S. aureus and MRSA colonization in Belgian CF patients and characterize the phenotype and clonal distribution of their staphylococcal strains.

METHODS

S. aureus isolated from CF patients attending nine CF centres were collected. Oxacillin resistance was detected by oxacillin agar screen and mecA PCR. Antibiotic susceptibility was tested by microdilution. MRSA strains were genotyped by PFGE and SCCmec typing and compared with hospital-associated MRSA strains.

RESULTS

Laboratories used a diversity of sputum culture procedures, many of which appeared substandard. S. aureus was isolated from 275/627 (44%) CF patients (20% to 72% by centre). The prevalence of SCV colonization was 4%, but SCVs were almost exclusively recovered from patients in two centres performing an SCV search. Phenotypically, 14% of S. aureus isolates were oxacillin-resistant: 79% carried mecA and 19% were SCVs lacking mecA. The mean prevalence of 'true' MRSA colonization was 5% (0% to 17% by centre). By PFGE typing, 67% of CF-associated MRSA were related to five epidemic clones widespread in Belgian hospitals.

CONCLUSIONS

This first survey of S. aureus colonization in the Belgian CF population indicated a diversity in local prevalence rates and in proportion of oxacillin-resistant and SCV phenotypes, probably related to variation in bacteriological methods. These findings underscore the need for standard S. aureus detection methods and MRSA control policies in Belgian CF centres.

Septicemia due to Solobacterium moorei in a patient with multiple myeloma

We report a case of bacteremia caused by Solobacterium moorei, an anaerobic, non-sporulated Gram-positive bacillus in a patient with a multiple myeloma. The source of infection was presumably related to multiple dento-alveolar abscesses. This is the first recovery of S. moorei from blood cultures.

Sensitivity of methods for the isolation of Escherichia coli O157 from naturally infected bovine faeces

At present, no standard protocol has been described to detect the presence of Escherichia coli O157 in cattle faeces. Therefore, the sensitivity of 26 different isolation methods was determined in order to recommend a method of choice. Faeces samples from 17 different beef cattle at a farm previously found positive for E. coli O157 were subdivided into a total of 40 samples. It was not known whether the 17 cattle shed E. coli O157 at the time of sampling. At another farm where cattle have been found negative for E. coli O157 on different occasions, five faeces samples were collected. Two methods yielded the highest sensitivity (74%): 6h enrichment in modified tryptone soya broth supplemented with novobiocin (mTSBn) followed by an immunomagnetic separation (IMS) with (i) Dynal beads or (ii) Captivate beads and selective plating on Rainbow agar (RA) plates. Enrichment for 6h was significantly better than 24h enrichment. Only after 24h, buffered peptone water (BPw) was significantly better than mTSBn. A sensitivity of 82% was obtained only when the two most sensitive tests were done simultaneously. Because none of the tests gave 100% sensitivity, it can be concluded that isolation rates of E. coli O157 from bovine faeces using only one of the tested procedures results in an underestimation of the incidence of E. coli O157 in cattle. Performing more than one test on the samples must be considered.

Isolation and molecular characterization of Escherichia coli O157 isolated from cattle, pigs and chickens at slaughter

From 1999 until 2001, 3625 food samples were examined for the presence of Escherichia coli O157. Samples were from bovine origin (ground beef, n=549; carcasses, n=2452), calves (carcasses, n=147), chicken (breast, n=203; carcasses, n=71) and pigs (carcasses, n=85; trimmings, n=118). Vidas ECO detected 451 (12%) samples positive, but from only 27 (0.74%) samples was E. coli O157 isolated. One strain was isolated from bovine ground beef (0.18%), one from a pig carcass (1.17%) and all others were isolated from bovine carcasses (1.02%). All strains possessed the attaching-and-effacing gene, the enterohemorrhagic plasmid and verotoxin (VT) genes, except the strain isolated from the pig carcass that was therefore eliminated. Six of the strains were urease-positive. Strains were typed by two DNA fingerprinting methods: random amplification of polymorphic DNA (RAPD) and pulsed field gel electrophoresis (PFGE). PFGE revealed a similarity of 71.05%, while RAPD was 77.36% similar. None of the typing methods were able to classify all urease-positive strains to one pattern. Strains in the same PFGE cluster did not belong to one RAPD cluster. This paper highlights that Belgian fresh meat at retail level can be contaminated with E. coli O157 and that two different typing methods divide strains into different types.

Isolation and characterization of enterohaemorrhagic Escherichia coli O157:1H7 from cattle in Belgium and Poland

EHEC O157 were isolated from faeces of Belgian and Polish beef slaughter cattle. In Belgium, 1281 faecal samples were analysed by immunomagnetic separation [IMS] after enrichment in buffered peptone water from June 1998 till July 1999. Eighty-one samples (6.3%) were positive for E. coli O157. Phage type 8 was most frequently found. Bulls between 1 and 2 years old, slaughtered in September and October were most frequently found positive. Atypical biochemical features were observed in some isolates: 22 (27%) isolates were urease positive and 1 (1.2%) isolate was unable to ferment lactose. In Poland, 551 faecal samples, taken from January 1999 till December 1999, were examined using exactly the same techniques. Four faecal samples (0.7%) were positive for O157 EHEC, yielding seven phage type 8 isolates. All positive samples were from cattle younger than 2 years. Positive samples occurred in August, September and October.

Effect of acid resistance of Escherichia coli O157:H7 on efficacy of buffered lactic acid to decontaminate chilled beef tissue and effect of modified atmosphere packaging on survival of Escherichia coli O157:H7 on red meat

The present study examined the effect of pH-independent acid resistance of Escherichia coli O157:H7 on efficacy of buffered lactic acid to decontaminate chilled beef tissue. A varied level of acid resistance was observed among the 14 strains tested. Eight strains were categorized as acid resistant, four strains as acid sensitive, and two strains demonstrated acid-inducible acid resistance. The survival of an acid-resistant (II/45/4) and acid-sensitive (IX/8/16) E. coli O157:H7 strain on chilled beef tissue treated with 1 and 2% buffered lactic acid, sterile water, or no treatment (control) was followed. A gradual reduction of E. coli O157:H7 was noticed during the 10 days of storage at 4 degrees C for each of the treatments. Decontamination with 1 and 2% buffered lactic acid did not appreciably affect the pathogen. Differences in the pH-independent acid resistance of the strains had no effect on the efficacy of decontamination. The effect of modified atmosphere packaging (MAP) on survival of E. coli O157:H7 in red meat was also studied. MAP (40% CO2/60% N2) or vacuum did not significantly influence survival of E. coli O157:H7 on inoculated sliced beef (retail cuts) meat compared to packing in air. The relative small outgrowth of lactic acid bacteria during storage under vacuum for 28 days did not affect survival of E. coli O157:H7. Neither lactic acid decontamination nor vacuum or MAP packaging could enhance reduction of E. coli O157:H7 on beef, thus underlining the need for preventive measures to control the public health risk of E. coli O157:H7.

Particular biochemical profiles for enterohemorrhagic Escherichia coli O157:H7 isolates on the ID 32E system

The ability of the ID 32E system to identify and discriminate 74 Escherichia coli O157 isolates among 106 E. coli non-O157 isolates was evaluated. The results showed atypical biochemical reactions but accurate identification at the species level and no unique biochemical profile numbers for E. coli O157, although these numbers were distinct from those of other serotypes.

Microbiology of the middle meatus: a comparison between normal adults and children

Middle meatal samples were obtained from 52 carefully selected healthy adults. In 75 per cent of the test subjects bacterial organisms were cultured. However, growth was often poor and the predominant species suggest a commensal flora: coagulase-negative staphylococci were retrieved from 35 per cent, Corynebacterium sp. from 23 per cent and Staphyloccus aureus from eight per cent of the adults. These data are very different from those previously obtained among children where--even in the absence of obvious ENT pathology--the most frequently cultured organisms were typical sinusitis pathogens: Haemophilus influenzae present in 40 per cent, Moraxella catarrhalis in 34 per cent and Streptococcus pneumoniae in 50 per cent of children. Furthermore, Streptococcus viridans and Neisseria sp., both organisms that might be able to inhibit colonization by some of the pathogens and found commonly among children, are virtually absent in healthy adults.

Bacteriology of the middle meatus in children

Little is known about the bacteriology of the middle meatus in children. Therefore, middle meatal samples were obtained from 50 children who underwent adenoidectomy or adenotonsillectomy, while a group of 50 children submitted to minor non-ENT surgical procedures, were used as a control group. Haemophilus influenzae, Moraxella catarrhalis and Streptococcus pneumoniae were the most frequent cultured organisms, not only in the ENT group (in 68, 50 and 60% of the children respectively) but also in the control group (40, 34 and 50%). These three potential pathogens were more frequently seen among the children of the ENT group but only for H. influenzae was the observed difference statistically significant (P = 0.009). On semiquantitative analysis, there seemed to be more negative cultures or cultures with only a few colonies in the control group, while the richer cultures were obtained from the ENT group. Again, only for H. influenzae, these differences reached a statistical significance (P = 0.003). Streptococcus viridans and Neisseria species, both organisms that might be able to inhibit colonisation by some of the pathogens, were more frequently cultured in the control than in the ENT group: Strep. viridans 30 vs. 10% (P = 0.025) and Neisseria species 14 vs. 2% (P = 0.069).

Microbiology of the middle meatus in children requiring adenotonsillectomy

Middle meatus samples were cultured in 120 children undergoing adenotonsillectomy with, or without, insertion of ventilation tubes. Every child (except one) had positive cultures. Haemophilus influenzae (62 per cent of the children), Moraxella catarrhalis (53 per cent) and Streptococcus pneumoniae (48 per cent) were the most commonly isolated bacteria. The presence of Moraxella catarrhalis and (to a lesser extent) Streptococcus pneumoniae was higher in younger children, while Haemophilus influenzae was cultured independently of age. Culture results of these middle meatal samples, carefully taken in order to avoid any contamination, probably reflect some ongoing sinus infection in these children requiring adenotonsillectomy. The problems inherent in the interpretation of surface cultures are addressed.

Severe encephalopathy in a child: an uncommon cause

Cat scratch disease (CSD) is usually a self-limited disease. Although extremely uncommon, the involvement of the central nervous system has been previously reported in CSD. The intention of this paper is to make physicians aware that CSD could be complicated by encephalopathy. Seizures in some patients could be the only clinical manifestation and are resistant to the common anti-epileptic therapy. The seizures resolve with supportive care.

Association of enterohemorrhagic Escherichia coli hemolysin with serotypes of shiga-like-toxin-producing Escherichia coli of human and bovine origins

In this study we investigated whether the enterohemorrhagic Escherichia coli (EHEC) hemolysin gene ehxA could be used as an indicator of pathogenicity in Shiga-like-toxin-producing Escherichia coli (SLTEC) isolates. The isolates in a collection of 770 SLTEC strains of human and bovine origins were assigned to group 1 (230 human and 138 bovine SLTEC isolates belonging to serotypes frequently implicated in human disease), group 2 (85 human and 183 bovine isolates belonging to serotypes less frequently implicated in disease), and group 3 (134 bovine isolates belonging to serotypes not implicated in disease). PCR amplification was used to examine all of the SLTEC isolates for the presence of ehxA and the virulence-associated genes eae, slt-I, and slt-II. The percentages of human isolates in groups 1 and 2 that were positive for ehxA were 89 and 46%, respectively, and the percentages of bovine isolates in groups 1 to 3 that were positive for ehxA were 89, 51, and 52%, respectively. The percentages of human isolates in groups 1 and 2 that were positive for eae were 92 and 27%, respectively, and the percentages of bovine isolates in groups 1 to 3 that were positive for eae were 78, 15, and 19%, respectively. The frequencies of both ehxA and eae were significantly higher for group 1 isolates than for group 2 isolates. The presence of the ehxA gene was associated with serotype, as was the presence of the eae gene. Some serotypes, such as O117:H4, lacked both eae and ehxA and have been associated with severe disease, but only infrequently. The slt-I genes were more frequent in group 1 isolates than in group 2 isolates, and the slt-II genes were more frequent in group 2 isolates than in group 1 isolates. In a second experiment we determined the occurrence of the ehxA and slt genes in E. coli isolated from bovine feces. Fecal samples from 175 animals were streaked onto washed sheep erythrocyte agar plates. Eight E. coli-like colonies representing all of the morphological types were transferred to MacConkey agar. A total of 1, 080 E. coli isolates were examined, and the ehxA gene was detected in 12 independent strains, only 3 of which were positive for slt. We concluded that the ehxA gene was less correlated with virulence than the eae gene was and that EHEC hemolysin alone has limited value for screening bovine feces for pathogenic SLTEC because of presence of the ehxA gene in bovine isolates that are not SLTEC.

Neonatal infections with Pseudomonas aeruginosa associated with a water-bath used to thaw fresh frozen plasma

In our 15-bed neonatal intensive care unit (NICU), four new-borns were found to be colonized or infected with Pseudomonas aeruginosa within a period of one week. To identify the outbreak source, three independent studies were performed: epidemiological investigation, environmental surveillance and genotypic typing of isolates. Although epidemiological investigation by a case-control study revealed no conclusive results, the transfusion of fresh frozen plasma (FFP) and human albumin (HA) appeared to be the factor with highest risk. Environmental surveillance and random amplification of polymorphic DNA (RAPD) of isolates identified a water-bath used to warm FFP and HA as the likely reservoir for the outbreak. Further spread of the organism did not occur after elimination of this water-bath from the NICU. RAPD identified in addition an isolate from an infant hospitalized in the NICU five months before the outbreak with a pattern matching the one of the outbreak cluster.

Microsurgical epididymal sperm aspiration with motile trophozoite cells but no spermatozoa

This paper reports on a patient in whom the clinical diagnosis of obstructive azoospermia was made according to clinical observations, i.e. azoospermia, normal andrological examination, normal follicle stimulating hormone and a misleading histopathological report of a testicular biopsy. Microsurgical vasoepididymostomy failed to restore fertility, and as a last resort, microsurgical sperm aspiration was performed. Although flagellated cells were observed in the epididymal aspiration, no spermatozoa were observed and wet preparation of multiple testicular biopsies failed to demonstrate any spermatozoon. This patient was diagnosed to have a non-obstructive azoospermia, resulting from maturation arrest associated with trichomonas infection at the level of the epididymis.

Prevalence of hepatitis A, B and C in the Flemish population

Viral hepatitis is a serious health problem throughout the world. No recent prevalence data on hepatitis A, B and C were available for the population in Flanders, Belgium. For this reason, a sero-epidemiological study was undertaken in 1993-1994 in a sample of the general population. The purpose of this study was to obtain a clear picture of the prevalence of hepatitis A, B and C. Between April 1993 and February 1994, 4,058 blood samples were drawn and collected in 10 hospitals in Flanders. The study group was representative for the Flemish population. For hepatitis A a seroprevalence of 55.1% was found. In the non-Belgian residents the HAV prevalence was significantly higher than in Belgians (62% versus 52%; chi2 = 8.05; p = 0.005). For hepatitis B. 9.9% of the study group showed serological evidence of hepatitis B markers: 6.9% of the participants was positive for anti-HBs/anti-HBc, 0.7% appeared to be HBsAg positive and 3.5% was solely anti-HBs positive. The prevalence of HBV markers in Belgians was 6.9%, significantly lower compared to the 13.4% among non-Belgians (chi 2 = 14.05; p = 0.00018). 4055 serum samples were analysed for hepatitis C serology by second generation anti-HCV tests. Anti-HCV was detected in 0.87% of the serum samples. No statistically significant difference was found in HCV prevalnece between Belgians and non-Belgians. Results of this study should help policy makers in their decisions on the most appropriate hepatitis A and B vaccination strategy and on the most effective prevention strategy for hepatitis C.

Splenic abscess with Clostridium novyi bacteraemia and sepsis

Splenic abscess is an uncommon entity and usually results in the death of the patient when left undiagnosed. A case is presented where bacteraemia with an anaerobic Gram-positive bacillus was associated with splenic abscess. Despite treatment with splenectomy and antibiotics the patient developed a multiple organ dysfunction syndrome (MODS) and died. Of particular interest was the isolation of Clostridium novyi type A from the blood in a patient without gas gangrene but with splenic suppuration.

Different clinical manifestations of meningococcaemia: three patient reports

Neisseria meningitidis, a ubiquitous Gram-negative diplococcus, is responsible for a spectrum of clinical manifestations. This is illustrated by the history of three patients recently admitted to our hospital. Because of the possibly rapid and dramatic evolution, awareness for meningococcal diseases remains obligatory. Adequate antibiotic treatment instituted as soon as the diagnosis is suspected and early application of aggressive supportive care can lead to more favourable outcome.

In vitro activity of amoxycillin/clavulanate and ticarcillin/clavulanate compared with that of other antibiotics against anaerobic bacteria: comparison with the results of the 1987 survey

The activity of amoxycillin/clavulanate (Augmentin) and ticarcillin/ clavulanate (Timentin) was tested against 351 strict anaerobic clinical isolates collected from September 1993 to April 1994 in eight Belgian university hospitals and compared with that of 8 other antibiotics using the NCCLS reference agar dilution procedure. Production of beta-lactamase was detected by the nitrocefin test in 48% of the isolates. At NCCLS-recommended breakpoints, more than 90% of isolates were susceptible to amoxycillin/clavulanate, ticarcillin/clavulanate, piperacillin/tazobactam, imipenem, chloramphenicol and metronidazole but only 77%, 72% and 48% to cefoxitin, clindamycin and penicillin, respectively. In comparison with the results of a similar survey conducted in 1987 no major changes in susceptibility were observed except for the susceptibility to clindamycin that declined from 83% to 72% overall, and from 83% to 66% in the B. fragilis group. Furthermore one isolate of Clostridium clostridioforme was found produce beta-lactamase and few B. fragilis group isolates showed reduced susceptibility to metronidazole.

Clonal relatedness of Shiga-like toxin-producing Escherichia coli O101 strains of human and porcine origin

Shiga-like toxin (SLT)-producing Escherichia coli (SLTEC) O101 has recently been associated with hemorrhagic colitis and hemolytic-uremic syndrome in humans. In this study, SLTEC O101 strains from humans and pigs were characterized for clonal relatedness by nucleotide sequence analysis of their slt genes, DNA finger-printing of genomic DNA, and determination of virulence factors. The slt genes of five E. coli O101 strains were cloned and sequenced. For all strains, the deduced amino acid sequences of the B subunits were identical to those of the SLT-IIe present in the classical SLTEC O139 strains that cause edema disease in pigs. The A subunit revealed more than 99% homology to that of SLT-IIe. DNA fingerprinting revealed a high degree of genetic relatedness between the human and porcine O101 isolates. None of the O101 strains investigated had virulence factors frequently found in porcine (F107 fimbriae or heat-stable or heat-labile enterotoxins) or human SLTEC strains (eaeA or enterohemorrhagic E. coli hemolysin). The absence of virulence factors typical of SLT-I- and SLT-II-producing E. Coli together with the presence of SLT-IIe, a toxin previously seen only in porcine E. coli, suggests a new pathogenic mechanism for E. coli O101 infection of humans. For diagnostic purposes, we recommend the use of PCR primers and DNA probes complementary to slt-IIe to correctly identify such strains and to further evaluate their role in human diseases.

Discrimination of epidemic and sporadic isolates of Arcobacter butzleri by polymerase chain reaction-mediated DNA fingerprinting

DNA polymorphisms of Arcobacter butzleri outbreak-related strains and Arcobacter reference strains were determined by use of the polymerase chain reaction with primers aimed at repetitive sequences. The epidemiological relationship among 14 outbreak-related strains was substantiated, as they showed virtually no genomic variations. Their DNA amplification patterns were, however, clearly different from those of all Arcobacter reference strains studied; each reference strain was characterized by a unique DNA fingerprint.

Bilateral fiberoptic bronchoalveolar lavage in acute unilateral lobar pneumonia

Bilateral cultures of bronchoalveolar lavage fluid were obtained from eight children with unilateral lobar pneumonia. In four patients bacterial pathogens were not isolated from lavage of the radiologically normal side but were subsequently cultured from the consolidated segment. This pattern helped to exclude contamination by oropharyngeal flora of bronchoalveolar lavage fluid. Bilateral bronchoalveolar lavage may help in the interpretation of lower respiratory tract cultures obtained by fiberoptic bronchoscopy.

Comparative study of cefetamet pivoxil and penicillin V in the treatment of group A beta-hemolytic streptococcal pharyngitis

The efficacy of cefetamet pivoxil (20 mg/kg and 10 mg/kg b.i.d.) was investigated in an open, prospective, randomized, comparative multicenter trial involving 148 children suffering from group A beta-hemolytic streptococcal (GABHS) pharyngo-tonsillitis. Phenoxymethylpenicillin given for 10 days was used as the reference drug and resulted in 15% treatment failures. After treatment with cefetamet pivoxil 20 mg/kg b.i.d., 2 failures (5.8%) were observed in 34 patients treated for 7 days and 2 (6%) in 33 patients after 10 days treatment. In 8 children treated with cefetamet pivoxil 10 mg/kg b.i.d. for 10 days, 7 were cured and 1 relapsed in the late follow-up. Recruitment for this dosage group is being continued. No serious adverse events occurred. Cefetamet pivoxil, given b.i.d., can be considered an alternative to phenoxymethylpenicillin in the treatment of GABHS pharyngo-tonsillitis.

Quality control in antimicrobial disk susceptibility testing: a Belgian multicenter study

A Belgian multicenter trial was conducted to evaluate problems encountered with quality control results of antimicrobial disk susceptibility testing and to compare the performance of BBL disks and Rosco tablets. Over a period of four weeks 18 laboratories daily tested three reference strains against eight antibiotics. A standardised method was used by all participants. For all results together 10.4% and 7.3% of the measurements with BBL disks and Rosco tablets, respectively, were outside the recommended range. Major problems were observed for some specific strain-antibiotic combinations. Standard deviations were similar for both systems; their precision was comparable. The results suggest that cooperation between manufacturers and some reference laboratories could be improved in order to establish optimal quality control limits.

Streptomycin pharmacokinetics in relapsing Mycobacterium xenopi peritonitis

Relapsing peritonitis due to Mycobacterium xenopi developed in an 80-year-old man undergoing continuous peritoneal dialysis after appropriately treated concurrent bacterial peritonitis. The patient presented with a lymphocytic exudative peritoneal drainage fluid. The diagnosis of tuberculous peritonitis was made by identification of acid-fast bacilli in peritoneal effluent and culture of M. xenopi. Oral antituberculous drugs in combination with intraperitoneal streptomycin achieved suppression of the disease, permitting peritoneal dialysis to be continued with satisfactory clearance and ultrafiltration capacity during a follow-up period of up to 35 months. Streptomycin kinetics revealed that 75% of the intraperitoneally administered dose of streptomycin is absorbed from the dialysate.

In-vitro activity of lomefloxacin in comparison with pefloxacin and ofloxacin

The in-vitro activity of lomefloxacin (SC 47111, NY-198) was investigated by the determination of MICs in agar and in broth, of MBCs in broth, of killing curves and of the duration of the post-antibiotic effect. MICs measured in broth and in agar were almost identical. Lomefloxacin was two- to eight-fold less active against Gram-positive bacteria than ofloxacin. Its activity against Staphylococcus aureus was independent of resistance to penicillin and oxacillin. The activity of lomefloxacin, ofloxacin and pefloxacin was poor against JK corynebacteria. Enterobacteriaceae, Aeromonas spp., Haemophilus, influenzae, Neisseriaceae and Campylobacter jejuni were highly susceptible to the three quinolones investigated. Non-fermenting Gram-negative bacilli were less susceptible. MBCs were within one dilution of the corresponding MICs. The killing rate was very high against Gram-negative bacilli (2.5-4.0 log cfu/ml reduction in 2 h) whereas it was low against Gram-positive bacteria (0.5-1.0 log cfu/ml reduction in 2 h). Emergence of resistance was not observed. The duration of the post-antibiotic effect with Gram-negative bacilli depended on the strain and species (median: 0.9-1.5 h). The post-antibiotic effect was insignificant with Staph. aureus.

In vitro activity of amoxycillin plus clavulanic acid and ticarcillin plus clavulanic acid compared with that of other antibiotics against anaerobic bacteria

The activity of amoxycillin/clavulanic acid (Augmentin) and ticarcillin/clavulanic acid (Timentin) was tested against 303 unselected clinical anaerobic isolates recently collected in seven Belgian university hospitals and compared with that of 11 other antimicrobial agents. Bacteroides spp. accounted for 52.1% of the isolates, Clostridium spp. for 23.4%, anaerobic cocci for 15.5%, nonsporeforming gram-positive bacilli for 4.6% and Fusobacterium spp. for 3.3%. Ticarcillin/clavulanic acid (fixed clavulanic acid concentration of 2 mg/l) was the most active drug with an overall susceptibility rate of 99.7%. Amoxycillin/clavulanic acid (fixed ratio of 2:1) and chloramphenicol inhibited 97.4% of the isolates, metronidazole 95.4%, piperacillin 92.4%, ticarcillin 91.4%, clindamycin 87.8%, cefotetan 81.2%, cefazolin 63.0%, cefuroxime 60.4%, erythromycin 57.8%, penicillin 57.1% and doxycycline 52.1%. beta-lactamases were detected exclusively in Bacteroides spp. isolates (79.1% positive).

A clinical and sero-epidemiological study of 190 Belgian patients suffering from Lyme borreliosis

We present a sero-epidemiological study of 190 Belgian cases of Lyme borreliosis, a multisystemic disease caused by the spirochaete Borrelia burgdorferi and transmitted by a tick bite. The whole spectrum of clinical pictures was observed in these patients, including "erythema chronicum migrans" (63%), neurological involvement (47%) and arthritis (22%), frequently in combination. Our results are compared to findings in other countries. Among the 437 Ixodes ricinus ticks collected in the Sambre and Meuse valleys around Namur, we discovered 43 ticks (9.8%) with spirochaetes in the midgut. The ecology of these arthropods explains why this infection is more prevalent in the spring and the summer. Perhaps for the same reason, the incidence ranges from low near the coast to medium in the central part and high in the wooded south-eastern part of Belgium. The main conclusions are that Lyme borreliosis is endemic in Belgium, that all the clinical pictures can be observed ant that a clear epidemiological case-definition is needed, combining clinical signs and serological results.