The role of Dutch guidelines in the diagnostic outcomes and treatment decisions of hospitalised older adults with a suspected urinary tract infection: a retrospective cohort study.

PURPOSE: Urinary tract infections (UTIs) are highly prevalent and difficult to diagnose in older adults. We aimed to evaluate the applicability of Dutch Association of Urology (NVU) and Dutch Association of Elderly Care Physicians (Verenso) guidelines in terms of diagnostic outcomes and treatment decisions in hospitalised older adults with suspected UTIs. METHODS: A retrospective cohort study was conducted on 225 geriatric patients with a urine culture taken in 2019, to determine conformity of the studied population to NVU and Verenso. RESULTS: Of 225 patients with suspected UTI (mean age 86 years; 56.4% female), 67.6% had urinary tract-related symptoms, of whom 96 received antibiotics, including those with a negative urine dipstick (n = 12) or urine culture (n = 28). Hundred seventy-seven and 147 patients were assessed and treated conforming to the NVU and Verenso guidelines, respectively. The 38 patients who were assessed and treated non-conforming to NVU, including patients with negative urine diagnostics, received antibiotics more often compared with 177 patients treated conforming to NVU (p < 0.001). A large number of patients with negative urine tests were treated conforming to Verenso and antibiotics were withheld in 75.5% of the patients. The non-conforming Verenso-treated patients with prescribed antibiotics had significantly more negative dipstick results (p = 0.05), fewer urinary tract-related symptoms (p < 0.001) and more often a different infectious focus (p < 0.001). CONCLUSION: The common practice performed on the studied geriatric population was more in accordance with the NVU guideline than Verenso. The results indicated that compliance with the guidelines might lead to fewer antibiotic prescriptions in the study population.

Umbilical Cord Procalcitonin to Detect Early-Onset Sepsis in Newborns: A Promising Biomarker.

Background: Up to 7% of neonates born in high-income countries receive antibiotics for suspected early-onset sepsis (EOS). Culture-proven neonatal sepsis has a prevalence of 0.2%, suggesting considerable overtreatment. We studied the diagnostic accuracy of umbilical cord blood and infant blood procalcitonin (PCT) in diagnosing EOS to improve antibiotic stewardship. Methods: Umbilical cord blood PCT was tested in newborns ≥ 32 weeks of gestation. Groups were defined as following: A) culture-proven or probable EOS (n = 25); B) Possible EOS, based on risk factors for which antibiotics were administered for <72 h (n = 49); C) Risk factor(s) for EOS without need for antibiotic treatment (n = 181); D) Healthy controls (n = 74). Additionally, venous or capillary blood PCT and C-reactive protein (CRP) were tested if blood drawing was necessary for standard care. Results: Between June 2019 and March 2021, 329 newborns were included. Umbilical cord blood PCT was significantly higher in group A than in group C and D. No difference between venous or arterial samples was found. Sensitivity and specificity for cord blood procalcitonin were 83 and 62%, respectively (cut-off 0.1 ng/mL). Antepartum maternal antibiotic administration was associated with decreased PCT levels in both cord blood and infant blood directly postpartum in all groups combined. Conclusion: Umbilical cord blood PCT levels are increased in newborns ≥32 weeks with a proven or probable EOS and low in newborns with risk factors for infection, but PCT seems not a reliable marker after maternal antibiotic treatment. PCT could be useful to distinguish infected from healthy newborns with or without EOS risk factors.

Viable Legionella pneumophila bacteria in natural soil and rainwater puddles.

AIMS: For the majority of sporadic Legionnaires' disease cases the source of infection remains unknown. Infection may possible result from exposure to Legionella bacteria in sources that are not yet considered in outbreak investigations. Therefore, potential sources of pathogenic Legionella bacteria--natural soil and rainwater puddles on roads--were studied in 2012. METHODS AND RESULTS: Legionella bacteria were detected in 30% (6/20) of soils and 3·9% (3/77) of rainwater puddles by amoebal coculture. Legionella pneumophila was isolated from two out of six Legionella positive soil samples and two out of three Legionella positive rainwater samples. Several other species were found including the pathogenic Leg. gormanii and Leg. longbeachae. Sequence types (ST) could be assigned to two Leg. pneumophila strains isolated from soil, ST710 and ST477, and one strain isolated from rainwater, ST1064. These sequence types were previously associated with Legionnaires' disease patients. CONCLUSIONS: Rainwater and soil may be alternative sources for Legionella. SIGNIFICANCE AND IMPACT OF THE STUDY: The detection of clinically relevant strains indicates that rainwater and soil are potential sources of Legionella bacteria and future research should assess the public health implication of the presence of Leg. pneumophila in rainwater puddles and natural soil.

Summer increase of Legionnaires' disease 2010 in The Netherlands associated with weather conditions and implications for source finding.

During August and September 2010 an unexpected high number of domestic cases of Legionnaires' disease (LD) were reported in The Netherlands. To examine this increase, patient characteristics and results of source finding and environmental sampling during the summer peak were compared to other domestic cases in 2008-2011. This analysis did not provide an explanation for the rise in cases. A similar increase in LD cases in 2006 was shown to be associated with warm and wet weather conditions, using an extended Poisson regression model with adjustment for long-term trends. This model was optimized with the new data from 2008 to 2011. The increase in 2010 was very accurately described by a model, which included temperature in the preceding 4 weeks, and precipitation in the preceding 2 weeks. These results confirm the strong association of LD incidence with weather conditions, but it remains unclear which environmental sources contributed to the 2010 summer increase.

Legionella prevention in the Netherlands: an evaluation using genotype distribution.

Legionnaires' disease (LD) is an acute pneumonia caused by the inhalation or aspiration of aerosols contaminated with Legionella bacteria. The watery environment is considered to be the natural habitat for these bacteria. Therefore, drinking water legislation is used in the primary prevention of LD, focussing on the different water sources to which the general public is exposed. For 10 years, secondary prevention of LD in the Netherlands has been organised using an outbreak detection programme that eliminates potential sources of infection that LD patients have been exposed to during their incubation period. To evaluate the two prevention strategies, we compared the distribution of Legionella pneumophila serogroup 1 genotypes isolated from patient material (n = 179) with the distribution resulting from primary (n = 182) and secondary (n = 60) prevention actions, respectively. The sequence type profiles were generated using the HiMLST method that employs next generation sequencing. We found that genotypes collected during primary prevention differ to a large extent from those isolated from patients. Genotypes collected during secondary prevention efforts had a greater similarity to that of patient isolates, but could be further improved. Our results suggest that primary prevention is not aiming at the correct reservoir, whereas secondary prevention is only partially focussed. It seems that there is a still unknown reservoir.

Wellness centres: an important but overlooked source of Legionnaires disease. Eight years of source investigation in the Netherlands, 1 August 2002 to 1 August 2010.

Visiting wellness centres is considered safe and relaxing and might provide health benefits for visitors with certain cardiovascular, dermatological or respiratory diseases. On the other hand, wellness centres could pose health risks, especially with respect to Legionnaires' disease. We investigated the role of wellness centres in the occurrence of Legionnaires' disease by analysing the data of eight years (2002­2010) of source investigation in the Netherlands. There were 15 wellness centres identified as potential sources of infection for a total of 35 Legionnaires' disease patients. Twelve of these centres were positive for Legionella spp.: six for Legionella pneumophila, six for non-pneumophila Legionella spp.. Of the 65 positive environmental samples found during the wellness centre investigations, 41 were derived from shower heads. For two centres, the Legionella pneumophila strains in the collected samples had a genotype that was indistinguishable from the patient isolates. These results show that wellness centres are potential sources of Legionnaires' disease.

Diagnostic testing for Legionnaires' disease in the Netherlands between 2007 and 2009: a possible cause for the decline in reported Legionnaires' disease patients.

Legionnaires' disease (LD) is an acute pneumonia caused by the inhalation or aspiration of aerosols contaminated with the Legionella bacteria. In the Netherlands, around 300 LD cases per year were reported between 2000 and 2008, but in 2009, the number dropped to 251, which was the lowest number in the previous 5 years of surveillance. We investigated if this decrease could be explained by the number of performed Legionella diagnostic tests in this year. We analyzed the number of tests performed between 2007 and 2009 in three large microbiological laboratories in different geographical regions in the Netherlands. Our data showed that there was no decrease in the number of patients for whom a diagnostic test for Legionella was performed in this period. These results are not in line with our hypothesis that the decrease in reported Legionella pneumonia patients in 2009 would be due to a decrease in patients for whom a diagnostic test was performed. We conclude that it is more likely that other factors such as the influence of weather patterns might explain the sudden drop in reported Legionella pneumonia patients in 2009 compared to the previous years, and it would be interesting to investigate this for the period described.

An outbreak of a multiresistant methicillin-susceptible Staphylococcus aureus (MR-MSSA) strain in a burn centre: the importance of routine molecular typing.

Here we report an outbreak among 17 patients caused by a single strain of a multiresistant methicillin-susceptible Staphylococcus aureus (MR-MSSA) in a burn centre. The MR-MSSA strains were resistant to penicillin, ciprofloxacin, erythromycin, clindamycin and co-trimoxazole. Further analysis showed an increased prevalence of MR-MSSA carriership in S. aureus colonized patients admitted to the burn centre, from 0% in 2005 (0/118), 3.3% in 2006 (4/121), 6.1% in 2007 (6/99), to 7.8% in 2008 (7/90). Molecular typing with amplified fragment length polymorphism showed that all MR-MSSA isolates derived from burn centre patients had a unique genotype, and was different compared to isolates derived from other hospital patients. All healthcare workers (HCWs) who worked in the burn centre during the outbreak were screened for nasal carriage with MR-MSSA. One HCW tested positive for a genotype of MR-MSSA that was indistinguishable from the genotype found in samples of the burned patients. No new cases of MR-MSSA colonization or infection were identified after the colonized HCW stopped working at the burn centre. The routine practice of molecular typing of collected S. aureus strains from both patients and HCWs will help to detect nosocomial spread in a burn centre, and opens the possibility of a rapid, almost pre-emptive response.

Serum uric acid and cognitive function and dementia.

Uric acid is a risk factor of cardiovascular disease, as well as a major natural antioxidant, prohibiting the occurrence of cellular damage. The relation between uric acid and cognitive decline, in which both vascular mechanisms and oxidative stress are thought to play a role, is unknown. Therefore we assessed the relation between serum uric acid levels and the risk of subsequent dementia in a prospective population-based cohort study among 4618 participants aged 55 years and over. Additionally, we investigated the relation between serum uric acid and cognitive function later in life (on average 11.1 years later) in a subsample of 1724 participants who remained free of dementia during follow-up. All analyses were adjusted for age, sex and cardiovascular risk factors. Our data showed that only after correcting for several cardiovascular risk factors, higher serum uric acid levels were associated with a decreased risk of dementia (HR, adjusted for age, sex and cardiovascular risk factors, 0.89 [95% confidence interval (CI) 0.80-0.99] per standard deviation (SD) increase in uric acid). In participants who remained free of dementia, higher serum uric acid levels at baseline were associated with better cognitive function later in life, for all cognitive domains that were assessed [adjusted difference in Z-score (95% CI) per SD increase in uric acid 0.04 (0.00-0.07) for global cognitive function; 0.02 (-0.02 to 0.06) for executive function; and 0.06 (0.02-0.11) for memory function], but again only after correcting for cardiovascular risk factors. We conclude that notwithstanding the associated increased risk of cardiovascular disease, higher levels of uric acid are associated with a decreased risk of dementia and better cognitive function later in life.