Perspectives of primary care physicians on academic detailing for antimicrobial stewardship: feasibility and impact assessment.

OBJECTIVE: To understand primary care physicians' perspectives on academic detailing from an antimicrobial stewardship team to combat antibiotic overuse for upper respiratory infections and bronchitis in the COVID-19 era, which will help prevent avoidable outpatient visits. METHODS: In this prospective study, 14 female Croatian physicians completed standardized qualitative interviews using a semi-structured guide. The data were analyzed using inductive methodology based on reflexive thematic analysis. We used a theoretically informed approach based on a conceptual framework of healthcare intervention implementability focused on three domains: acceptability, fidelity, and feasibility. RESULTS: We identified six key themes highlighting barriers to changing prescribing practices, with patient pressure and specialist recommendations having an impact on the effectiveness of academic detailing. Despite challenges, primary care physicians described appreciation of direct interaction with evidence-based practices and reported usefulness, effectiveness, and further need for academic detailing. CONCLUSION: This study highlights the complex dynamics involved in implementing healthcare interventions and provides valuable insights for enhancing strategies directed at improving antibiotic prescribing practices. Specifically, our findings emphasize factors influencing behavior changes in physicians' antibiotic prescribing. The authors advocate for a collaborative approach involving community and hospital-based professionals to provide tailored guidance and address questions, ultimately improving prescribing practices.

Impact of the COVID-19 pandemic on hospital antimicrobial consumption in Croatia.

OBJECTIVES: The aim of the study was to assess the impact of the COVID-19 pandemic on antimicrobial consumption (AMC) in the hospital sector in Croatia by analysing data reported to the European Surveillance of Antimicrobial Consumption Network (ESAC-Net) between 2016 and 2020. METHODS: AMC was measured as the number of DDDs/1000 inhabitants/day and as the number of DDDs/100 bed days. To assess trends, linear regression was performed. To assess the impact of the pandemic on AMC, the compound annual growth rate was calculated for the years preceding the pandemic based on which AMC for 2020 was forecasted and compared with the actual consumption. RESULTS: While hospital AMC expressed as DDDs/1000 inhabitants/day between 2019 and 2020 decreased by 17%, when expressed as DDDs/100 bed days, an 8% increase was observed. Hospital consumption of antibacterials for systemic use in the 5 year period did not significantly change when expressed as DDDs/1000 inhabitants/day, while it statistically significantly increased when expressed as DDDs/100 bed days. An increasing trend in consumption of broad-spectrum antimicrobials was found. CONCLUSIONS: During the pandemic there was an increase in hospital AMC with a shift towards broad-spectrum antimicrobials requiring further in-depth qualitative analysis based on patient-level data. Contrasting results obtained using different denominators indicate that the metric DDDs/1000 inhabitants/day is not sensitive enough to evaluate hospital AMC. When assessing hospital AMC, the population under surveillance should be relevant for healthcare context. Antimicrobial stewardship remains one of the most important strategies to tackle antimicrobial resistance and antimicrobial surveillance methods must be as sensitive as possible.

Outbreak of healthcare-associated bacteremia caused by Burkholderia gladioli due to contaminated multidose vials with saline solutions in three Croatian hospitals.

OBJECTIVES: Burkholderia gladioli has been associated with infections in patients with cystic fibrosis, chronic granulomatous disease, and other immunocompromising conditions. The aim of this study was to better depict the outbreak of healthcare-associated bacteremia caused by B. gladioli due to exposure to contaminated multidose vials with saline solutions. METHODS: An environmental and epidemiologic investigation was conducted by the Infection Prevention and Control Team (IPCT) to identify the source of the outbreak in three Croatian hospitals. RESULTS: During a 3-month period, 13 B. gladioli bacteremia episodes were identified in 10 patients in three Croatian hospitals. At the time of the outbreak, all three hospitals used saline products from the same manufacturer. Two 100-ml multidose vials with saline solutions and needleless dispensing pins were positive for B. gladioli. All 13 bacteremia isolates and two isolates from the saline showed the same antimicrobial susceptibility patterns and pulsed-field gel electrophoresis profile, demonstrating clonal relatedness. CONCLUSION: When an environmental pathogen causes an outbreak, contamination of intravenous products must be considered. Close communication between the local IPCT and the National Hospital Infection Control Advisory Committee is essential to conduct a prompt and thorough investigation and find the source of the outbreak.

Distribution of rotavirus genotypes in three Croatian regions among children ≤5 years of age (2012-2014).

OBJECTIVES: Rotavirus is the major cause of severe diarrhea in young children worldwide. In countries like Croatia, where rotavirus vaccine has not been introduced in the national immunization program, prospective surveillance is necessary to establish the diversity of rotavirus strains. The aim of this study was to describe the prevalence and geographical distribution of rotavirus strains in Croatia and to detect the possible emergence of novel strains. METHODS: The study was conducted among children ≤5 years of age with acute gastroenteritis at three hospitals located in different geographical regions of Croatia, during the years 2012 to 2014. Rotavirus was detected in stools using an immunochromatographic assay and then sent for further molecular analysis. RESULTS: Genotyping of 822 rotaviruses showed that the predominant circulating strain was G1P[8] (61.9%), followed by G2P[4] (19.5%), G1P[4] (3.9%), and G3P[8] (2.9%). A high prevalence of reassortants among common human rotavirus genotypes was detected (7.7%). Possible zoonotic reassortants were found, including G8 and G6 strains. The latter is described for the first time in Croatia. CONCLUSIONS: This study represents pre-vaccination data that are important for decisions regarding immunization strategies in Croatia. The high prevalence of 'common' rotavirus strains circulating in Croatia may advocate for rotavirus vaccine introduction, but further surveillance is necessary to monitor the possible emergence of novel genotypes.

Expression of KIR2DS1 does not significantly contribute to NK cell cytotoxicity in HLA-C1/C2 heterozygous haplotype B donors.

NK cells are functionally controlled by the killer immunoglobulin-like receptor (KIR) family that comprises inhibitory (iKIR) and activating (aKIR) members. Genetic association studies suggest that donors expressing aKIRs next to iKIRs will be superior donors in the setting of hematopoietic stem cell transplantation of patients with leukemia. However, contrary evidence states that aKIR expression may be irrelevant or even detrimental. Using a complex methodology incorporating KIR-Q-PCR, double fluorescence and viSNE analysis, we characterized subset distribution patterns and functionality in haplotype A donors which lack aKIRs and haplotype B donors that express a variety of B-specific genes. Here, we show that the alloreactive KIR2DS1+ NK cell subset in HLA-C1/C2 donors is highly responsive towards C2-expressing targets but quantitatively small and as such does not significantly contribute to cytotoxicity. Thus, we fail to find a direct link between haplotype allocation status and NK cell cytotoxicity at least in HLA-C1/C2 heterozygous donors.

Tumor-priming converts NK cells to memory-like NK cells.

Fascinating earlier evidence suggests an intrinsic capacity of human natural killer (NK) cells to acquire adaptive immune features in the context of cytomegalovirus (CMV) infection or pro-inflammatory cytokine stimulation. Since the role of memory NK cells in cancer has so far remained elusive and adoptive NK cell transfer in relapsing pediatric acute B cell precursor leukemia (BCP-ALL) patients awaits improvement, we asked the question whether tumor-priming could promote the generation of memory NK cells with enhanced graft-vs.-leukemia (GvL) reactivity. Here, we provide substantial evidence that priming of naive human NK cells with pediatric acute B cell leukemia or acute myeloid leukemia specimens induces a functional conversion to tumor-induced memory-like (TIML)-NK cells displaying a heightened tumor-specific cytotoxicity and enhanced perforin synthesis. Cell cycles analyses reveal that tumor-priming sustainably alters the balance between NK cell activation and apoptosis in favor of survival. In addition, gene expression patterns differ between TIML- and cytokine-induced memory-like (CIML)-NK cells with the magnitude of regulated genes being distinctly higher in TIML-NK cells. As such, the tumor-induced conversion of NK cells triggers the emergence of a so far unacknowledged NK cell differentiation stage that might promote GvL effects in the context of adoptive cell transfer.

KPC-Producing Klebsiella pneumoniae Isolates in Croatia: A Nationwide Survey.

BACKGROUND: In the last few years, Klebsiella pneumoniae strains producing K. pneumoniae carbapenemase (KPC) enzymes have emerged as important multidrug-resistant pathogens in hospitalized patients. This report describes KPC-producing isolates collected through the Croatian antimicrobial resistance surveillance program in the early stage of their dissemination in Croatia. MATERIALS AND METHODS: Forty-eight KPC-producing K. pneumoniae isolates, collected during a period from February 2011 to August 2013, were analyzed in this study. Antimicrobial susceptibility profiles were determined using disk diffusion and E-test. Pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST) were used for epidemiological analysis. Identification of ß-lactamase genes and associated antibiotic resistance mechanisms was performed by polymerase chain reaction and positive products were sequenced. Localization of blaKPC was investigated by S1 PFGE and Southern hybridization. RESULTS: Of 40 participating centers in Croatia, KPC isolates were recorded in 9 of them. They all had multidrug-resistant phenotype, but showed varying levels of resistance to carbapenems. All isolates displayed ST258, and PFGE showed that all but one were closely related. All isolates harbored blaKPC-2. Isolate with a unique PFGE pattern produced TEM-1, while others produced TEM-116. All isolates harbored blaSHV-11, but were negative for blaCTX-M and blaAmpC genes. All isolates contain one KPC-harboring plasmid, ranging in size from ∼60 to ∼210 kb, characterized as FIIs and IncR. CONCLUSION: This report describes that the early stage of KPC-producing K. pneumoniae dissemination in Croatia is associated with a prolific PFGE type belonging to ST258. So far, the spread of an outbreak strain is limited to the northwest region of the country.

Prevalence and molecular characteristics of methicillin-resistant Staphylococcus aureus strains isolated in a multicenter study of nursing home residents in Croatia.

BACKGROUND: Residents of nursing homes (NHs) are often hospitalized and could present a potential reservoir for methicillin-resistant Staphylococcus aureus (MRSA). The aim of the study was to determine the prevalence for MRSA carriage in residents and staff in Croatian NHs and to characterize MRSA strains using genotyping techniques. METHODS: A cross-sectional study was performed among 877 residents and staff of 7 NHs representing 3 major Croatian regions. Nasal swabs from residents and staff and other samples from residents with invasive devices were obtained. Identified isolates were submitted to susceptibility testing and genotyping with SCCmec typing, S aureus protein A (spa) locus typing, and pulsed-field gel electrophoresis (PFGE). RESULTS: The overall prevalence of MRSA colonization was 7.1% (95 confidence interval, 5.4%-8.8%), ranging from 0% to 28.8%. Four MRSA isolates were found in NH staff. All MRSA isolates were negative for Panton-Valentine leukocidin-encoding genes. SCCmec type II was found in 32 MRSA strains; SCCmec IV, in 27 strains; SCCmec I, in 3 strains. The predominant spa type was t008, found in 49 strains; PFGE analysis revealed 2 major clonal groups. CONCLUSIONS: MRSA strains were found to be colonizing residents and staff of 7 NHs in Croatia. Our study demonstrates the spread of 2 clones within and among Croatian NHs. The data presented here provide an important baseline for future surveillance of MRSA in NH.

Antibiotic use in eastern Europe: a cross-national database study in coordination with the WHO Regional Office for Europe.

BACKGROUND: There are no reliable data on antibiotic use in non-European Union (EU) southern and eastern European countries and newly independent states. We aimed to collect valid, representative, comparable data on systemic antimicrobial use in these non-EU countries of the WHO European region. METHODS: Validated 2011 total national wholesale antibiotic-use data of six southern and eastern European countries and regions and seven newly independent states were analysed in accordance with the WHO anatomical therapeutic chemical (ATC)/defined daily doses (DDD) method and expressed in DDD/1000 inhabitants per day (DID). FINDINGS: Total (outpatients and hospital care) antibiotic use ranged from 15·3 DID for Armenia to 42·3 DID for Turkey. Co-amoxiclav was mainly used in Georgia (42·9% of total antibiotic use) and Turkey (30·7%). Newly independent states used substantial quantities of ampicillin and amoxicillin (up to 55·9% of total antibiotic use in Azerbaijan). Montenegro and Serbia were the highest consumers of macrolides (15·8% and 19·5% of total antibiotic use, respectively), mainly azithromycin. Parenteral antibiotic treatment is common practice: 46·4% of total antibiotic use in Azerbaijan (mainly ampicillin; 5·3 DID) and 31·1% of total antibiotic use in Tajikistan (mainly ceftriaxone; 4·7 DID). INTERPRETATION: This study provides publicly available total antibiotic-use data for 13 non-EU countries and areas of the WHO European region. These data will raise awareness of inappropriate antibiotic use and stimulate policy makers to develop action plans. The established surveillance system provides a method to develop quality indicators of antibiotic use and to assess the effect of policy and regulatory actions. FUNDING: Netherlands Ministry of Health, Welfare, and Sport, and EU.

[Significance of laboratory statistics in tuberculosis control in Medimurje County]. / Znacenje laboratorijskih podataka u nadzoru nad tuberkulozom u Medimurskoj zupaniji.

UNLABELLED: Microbiological diagnosis of tuberculosis is the axis of any national tuberculosis control program. Tuberculosis notification rate in Medimurje County has been equivalent to the national average, except in 2009 when it (23/100,000) surpassed the national rate of 19.3/100,000. The aim of this study was to analyze laboratory results (age, sex, site of the disease, drug susceptibility test results, and genotyping results) in tuberculosis control in Medimurje County. MATERIAL, METHODS AND RESULTS: A prospective study of genotyping all newly isolated Mycobacterium tuberculosis strains is currently conducted at the Croatian National Institute of Public Health, Tuberculosis Diagnostic Department. The genotyping method used is determining variable number of tandem repeats of mycobacterial repetitive interspersed unit. Between 2007 and 2009, a total of 59 strains from patients coming from Medimurje County were genotyped, 27 (45.8%) of which had a unique genotype in the national database, while 32 (54.2%) were grouped in 22 clusters with 2 to 22 pertaining strains. Two of 22 clusters, one with two and one with five members each, were made up from strains isolated solely in Medimurje County. These strains are not only characteristic of the County, but the patients they originated from had most likely been exposed to the same route of transmission. The remaining 25 strains were grouped in 20 clusters. The patients they came from were from different parts of Croatia, while the number of Medimurje natives in these clusters varied between 1 and 3. A relatively high percentage of strains of unique genotype pointed to a relatively low degree of recent transmission. The results of molecular epidemiology analysis as part of monitoring the routes of tuberculosis transmission, showed the efficiency of counter epidemic measures by detection of unexpected routes of transmission and by identification of strains present in a given community, which more often than others cause disease.

[Guidelines for prevention, control and treatment of infections caused by methicillin-resistant Staphylococcus aureus (MRSA): changes and updates of chapter 7.0: treatment of patients with MRSA infection]. / Smjernice za prevenciju, kontrolu i lijecenje infekcija koje uzrokuje meticilin-rezistentni Staphylococcus aureus (MRSA): izmjena i dopuna poglavlja 7.0.: lijecenje bolesnika s MRSA - infekcijom.

Methicillin-resistant Staphylococcus aureus (MRSA) is an important pathogen throughout the world, and as well in Croatia. Therefore it was decided to develop guidelines with the aim to reduce the number of patients infected/colonized with MRSA in healthcare facilities and in nursing homes in Croatia, consequently reducing MRSA-related morbidity and mortality. An interdisciplinary team of experts developed these guidelines using existing international guidelines from different countries, and literature reviews about prevention, control, treatment and laboratory diagnosis of MRSA infections. Grades of evidence for specific recommendations were determined using CDC/HICPAC grading system. Categorization is based on existing data, theoretical basis, applicability and economic impact. After a broad discussion in different professional societies, Guidelines were accepted. In the meantime, several new possibilities appeared in the treatment of patients with MRSA infections in Croatia, so the Chapter 7.0 Treatment of patients with MRSA infections is changed and updated according to the new treatment possibilities. The rest of the Guidelines was not changed.

[Guidelines for prevention, control and treatment of infections caused by methicillin-resistant Staphylococcus aureus (MRSA)]. / Smjernice za prevenciju, kontrolu i lijecenje infekcija koje uzrokuje meticilin-rezistentni Staphylococcus aureus (MRSA).

Methicillin-resistant Staphylococcus aureus (MRSA) is an important pathogen throughout the world, and in Croatia as well. Therefore it was decided to develop guidelines with the aim to reduce the number of patients infected/colonized with MRSA in healthcare facilities and in nursing homes in Croatia, consequently reducing MRSA-related morbidity and mortality. An interdisciplinary team of experts developed these guidelines using existing international guidelines from different countries, and literature reviews about prevention, control, treatment and laboratory diagnosis of MRSA infections. Grades of evidence for specific recommendations were determined using CDC/HICPAC grading system. Categorization is based on existing data, theoretical basis, applicability and economic impact. After a broad discussion in different professional societies, Guidelines were accepted. Guidelines include recommendations for measures in prevention of MRSA spread, role of hospital management, rational use of antibiotics, measures in a case of outbreak, treatment of infections and brief review of community-acquired MRSA. At the end, appendices concerning hospital audit, algorithms of laboratory diagnosis, patient information and form for national MRSA surveillance were added.

Usefulness of multiple-locus VNTR fingerprinting in detection of clonality of community- and hospital-acquired Staphylococcus aureus isolates.

Staphylococcus aureus has become a major source of hospital infections and the risk of colonisation and infection by community-acquired methicillin-resistant S. aureus (CA-MRSA) is increasingly higher. Because of the importance of S. aureus to public health, many molecular typing methods have been developed to determine its transmission routes and source of infection during epidemiological investigations. In this study we evaluated the usefulness of multiplex PCR based Multi-Locus VNTR Fingerprinting (MLVF) as the first step method for rapid differentiation of Croatian and Polish S. aureus isolates in hospital and community settings. This is a first report of the usefulness of MLVF in typing of hospital-acquired methicillin-sensitive S. aureus (HA-MSSA) and four CA-MRSA isolates. A total of 47 isolates of S. aureus recovered in Croatia in 2004 and in Poland in 2006 and 2007 were tested. The MLVF results were compared to those produced by other typing methods, such as Pulsed-Field Gel Electrophoresis (PFGE), Multi-Locus Sequence Typing (MLST) and spa typing. The MLVF analysis showed almost the same clonality results as the remaining typing methods although some differences were found. Epidemiological data about the relation among S. aureus isolates and the results produced by typing methods applied in the present study indicate that because of the advantages in ease and speed of Variable Number of Tandem Repeats (VNTR) procedure over PFGE, spa typing and MLST, MLVF can be used as a first screening method followed by additional typing.

[Surveillance of antibiotic resistance and antibiotic consumption in Medimurje]. / Pracenje rezistencije bakterija na antibiotike i potrosnja antibiotika u Medimurju.

INTRODUCTION: Bacterial resistance is a global problem. More than 60 years of the large-scale use of antibiotics have resulted in a number of microorganisms which are resistant or multiresistant to different antimicrobial drugs. A correlation between the use of antibiotics and bacterial resistance has been proved for many different groups of antibiotics. AIM: The aim of this study was to determine the connection between bacterial resistance and antibiotic consumption in the region. MATERIAL AND METHODS: The surveillance of antibacterial resistance in Medimurje started in 1997 as part of the activities of the Croatian Commitee for Antibiotic Resistance Surveillance at the Academy of Medical Sciences of Croatia. The utilization of antibiotics was defined according to WHO and expressed in defined daily doses. The surveillance of their consumption and comparison of different drugs and different regions is done by TID (Thousands of Inhabitants Daily), which describes the population proportion taking a drug in a particular region per day. The analysis of antibiotic consumption was based on distribution data. RESULTS: The consumption of antibiotics according to the ATC/TID system in Medimurje in 2002 was 18.06 TID; TID was 0.86 and 17.2 for inpatients and outpatients, respectively. The consumption was recorded for the penicillin group of antibiotics in both hospital and outpatient utilization, followed by cephalosporins, tetracyclines and macrolides in outpatient utilization, and by cephalosporins, aminoglycosides and quinolones in hospital utilization. Analysis of the consumption of the penicillin group of antibiotics in outpatient utilization revealed it to be predominated by the wide spectrum penicillins and co-amoxiclav, whereas the latter prevailed in hospital utilization. The surveillance of bacterial resistance in Medimurje during the last 5 years (1998-2002) pointed to a high resistance to macrolides (23%-33%) in BHS. The outpatient utilization of macrolides was on the 4th place with 1.15 TID. Azithromycin accounted for 87% of macrolide consumption. In this region, pneumococci showed an extremely high rate of penicillin resistance (49%-68%), although this resistance was mostly intermediate. It was obviously due to the high selective antibiotic requirements, especially for the strains involving respiratory tract. High resistance to macrolides (15%-38%), cotrimoxasol (42%-50%) and tetracyclines (30%) pointed to the high proportion of multiresistant pneumococcal strains. A significantly lower resistance to penicillin (30%), which was strictly intermediate, was recorded in isolates from primary sterile materials. Resistance to other antibiotic groups was also lower. The rate or MRSA in the group of S. aureus as 2%-3% in the five-year period. E. coli was the most frequent isolate in both inpatient and outpatient settings. Analysis of resistance during the last 5 years yielded no specific findings. The resistance of wide spectrum penicillin was 51%-58%, with a very low portion of ESBL strains (<1%), no imipenem resistant strain; resistance to quinolones was 4%-8%, and to cotrimoxasole was 30%. There were no invasive E. coli strains resistant to 2nd and 3rd generations of cephalosporins, aminoglycosides, quinolones and carbapenemes, while the resistance to wide spectrum penicillin, 1st generation cephalosporins and cotrimoxasole was the same as in other groups of E. coli. DISCUSSION: Surveillance of antibiotic resistance in a local region is very important, because it shows the local pattern of resistance, helps choose useful empirical therapy and most efficacious antibiotic therapy, and can modify antibiotic therapy accordingly. CONCLUSION: There is no clear correlation between antibiotic consumption and bacterial resistance, especially in case of outpatient isolates.

Incidence, epidemiology, and characteristics of quinolone-nonsusceptible Streptococcus pneumoniae in Croatia.

Among 585 Streptococcus pneumoniae strains isolated in 22 Croatian hospitals 21 strains (3.6%) were quinolone nonsusceptible. MICs of all quinolones were high for seven strains tested with the same serotype (23F) and mutations in gyrA, parC, and parE. The remaining 14 strains were more heterogeneous and had mutations only in parC and/or parE, and the MICs of quinolones were lower for these strains.