Protocol for a systematic review and meta-analysis on Janus kinase inhibitors in the management of vitiligo.

BACKGROUND: Vitiligo is a disease that affects people of all skin shades and can impact their quality of life. Reliable evidence on the effectiveness and adverse events associated with the recent use of Janus kinase (JAK) inhibitors to treat vitiligo is needed. This protocol for a systematic review and meta-analysis seeks to collect evidence from both randomized controlled trials (RCTs) and observational studies to determine the effectiveness and patient-centered outcomes concerning treatment with JAK inhibitors. METHODS: We will conduct a systematic review of the literature for RCTs and observational studies that used upadacitinib, ritlecitinib, brepocitinib, ifidancitinib, cerdulatinib, deglocitinib, baricitinib, tofacitinib, and ruxolitinib JAK inhibitors as treatments for vitiligo compared to placebo, no treatment, or combination therapies. We will systematically search from inception in Epistemonikos, MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, EMBASE, ClinicalTrials.gov, PsycINFO, Allied and Complementary Medicine Database, Latin American and Caribbean Health Sciences Literature, Web of Science Core Collection, relevant preprint servers, and the gray literature. Ethics approval was not sought as the protocol and systematic review will not involve human participants, but rather summarized and anonymous data from studies. Primary outcomes include quality of life, percentage repigmentation, decreased vitiligo within 1 year or more, lasting repigmentation after a 2-year follow-up, cosmetic acceptability of repigmentation and tolerability or burden of treatment, and adverse events. Secondary outcomes are patient and study characteristics. We will include full-text articles, preprints, and clinical trial data in any language and all geographic regions. For data sources unavailable in English, we will obtain translations from global collaborators via the Cochrane Engage network. We will exclude articles for which sufficient information cannot be obtained from the authors of articles and systematic reviews. At least two investigators will independently assess articles for inclusion and extract data; reliability will be assessed before subsequent selection and data extraction of remaining studies. The risk of bias and certainty of evidence with Grading of Recommendations Assessment, Development, and Evaluation guidelines will be assessed independently by at least two investigators. We will estimate treatment effects by random-effects meta-analyses and assess heterogeneity using I2. Data that cannot be included in the meta-analysis will be reported narratively using themes. DISCUSSION: The proposed systematic review and meta-analysis describe the methods for summarizing and synthesizing the evidence on the effectiveness and patient-centered outcomes concerning the treatment of vitiligo with JAK inhibitors that were recently approved for this indication. To disseminate further the results of our systematic review, we plan to present them at international conferences and meetings. Our findings will provide robust evidence to facilitate decision-making at the policy or practitioner level. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42023383920.

Connexin 37, 40, 43 and Pannexin 1 Expression in the Gastric Mucosa of Patients with Systemic Sclerosis.

Systemic sclerosis (SSc) is an autoimmune disease characterized by fibrosis of the skin and internal organs. Although its pathogenesis is not fully understood, connexins (Cxs) and pannexins (Panx) could be involved in the process of fibrosis. We analyzed the protein expression of Cx37, Cx40, Cx43, and Panx1 in the gastric mucosa of patients with SSc and healthy volunteers, using immunofluorescence staining. Protein levels of Cx37 were slightly increased, while the levels of Cx40 were significantly decreased in the lamina propria of the gastric mucosa of SSc patients compared to the controls. The changes were proportional to SSc severity, with the most prominent changes found in patients with severe diffuse cutaneous SSc. No differences in Cx43 or Panx1 levels were found between the analyzed groups of samples. The lack of changes in Cx43 expression, which has been previously associated with fibrosis, could be due to the weak expression of Cx43 in the gastric mucosa in general. Further studies on full-thickness gastric biopsies containing muscle layers and animal SSc models are needed to fully elucidate the role of Cxs and Panxs in SSc-associated fibrosis.

The Distribution of Innervation and Immune Cell Infiltration Is Different in Genital and Extragenital Variants of Lichen Sclerosus.

Lichen sclerosus (LS) is a progressive skin disease that is characterized by chronic inflammation of either genital or extragenital skin, and it disproportionately affects women. We analyzed the distribution of nerve fibers, vanilloid receptors, cell proliferation, mast cells and macrophages in genital and extragenital LS samples, as well as in healthy skin, by using immunohistochemistry. The total amount of intraepidermal nerve fibers was lower in LS samples compared to healthy controls, while the total amount of subepidermal nerve fibers and calcitonin gene-related peptide (CGRP) positive fibers was higher in genital LS samples compared to both extragenital LS and healthy controls. Cell proliferation, macrophage and mast cell density were increased in LS samples compared to healthy controls. Genital LS had a higher macrophage density compared to the extragenital variant. Mast cell distribution significantly differed between genital and extragenital LS samples, even though their total mast cell densities were similar. These findings could explain the differences between pruritic symptoms of genital and extragenital LS and provide targets for the research of novel therapeutic strategies for LS management.

Fibrosis-Associated Signaling Molecules Are Differentially Expressed in Palmar Connective Tissues of Patients with Carpal Tunnel Syndrome and Dupuytren's Disease.

Carpal tunnel syndrome (CTS) and Dupuytren's disease (DD) are fibrotic conditions that affect the connective tissue of the hand and limit its functionality. The exact molecular mechanism underlying the fibrosis is unknown, and only some profibrotic factors have been investigated. In this cross-sectional study, we analyzed the expression of FGF signaling pathway molecules associated with fibrotic changes in the palmar fascia and the flexor retinaculum of 15 CTS patients and both clinically affected and unaffected palmar fascia of 15 DD patients, using immunofluorescence techniques. The expression of FGFR1, FGFR2, and CTGF in the blood vessel walls and surrounding connective tissue cells differed significantly between the analyzed groups, with changes in expression present even in clinically unremarkable tissues from DD patients. We also found altered expression of the analyzed factors, as well as TGF-ß1 and syndecan-1 in DD-associated sweat glands, possibly implicating their role in the pathophysiology of the disease. The increased expression of profibrotic factors in the clinically unaffected palmar fascia of DD patients may indicate that more extensive excision is needed during surgical treatment, while the profibrotic factors could be potential targets for developing pharmacological therapeutic strategies against DD-associated fibrosis.

The first characterized carbapenem-resistant Bacteroides fragilis strain from Croatia and the case study for it.

An imipenem-resistant Bacteroides fragilis strain was isolated from the blood of a 72-year-old male patient with a urinary bladder tumor in Osijek, Croatia. This strain was also resistant to ampicillin, piperacillin/tazobactam, cefoxitin, clindamycin, tetracycline, and harbored cfiA, ermF, and tetQ genes where the high-level expression of the cfiA carbapenem-resistant gene was driven by an IS1187 element. Interestingly, despite the carbapenem-resistant feature of the B. fragilis from blood, the patient relatively easily recovered from the bacteremia. It was the first characterized imipenem-resistant B. fragilis isolate with its case report from Croatia, which confirmed the appearance of carbapenem-resistant B. fragilis strains, that continues worldwide with low incidence and the molecular characteristics vary temporally and geographically.

In vitro effect of subminimal inhibitory concentrations of antibiotics on the biofilm formation ability of Acinetobacter baumannii clinical isolates.

The ability of A cinetobacter baumannii strains to form biofilm is one of the most important virulence factor which enables bacterial survival in a harsh environment and decreases antibiotic concentration as well. Subminimal inhibitory concentrations (subMICs) of antibiotics may change bacterial ultrastructure or have an influence on some different molecular mechanisms resulting in morphological or physiological changes in bacteria itself. The aim of this study was to determine effects of 1/2, 1/4, 1/8 and 1/16 minimal inhibitory concentrationsof imipenem, ampicillin-sulbactam, azithromycin, rifampicin and colistin on biofilm formation ability of 22 biofilm non-producing and 46 biofilm producing A. baumannii strains (30 weak producing strains and 16 moderate producing strains). Results of this study indicate that 1/2-1/16 MICs of imipenem, azithromycin, and rifampicin can reduce bacterial biofilm formation ability in moderate producing strains (p < 0.05), whereas 1/16 MIC of imipenem and 1/4-1/8 MICs of rifampicin reduce the biofilm formation in weak producing strains (p < 0.05). Statisticaly significant effect was detected among biofilm non-producing strains after their exposure to 1/16 MIC of azithromycin (p = 0.039). SubMICs of ampicillin-sulbactam and colistin did not have any significant effect on biofilm formation among tested A. baumannii strains.

Diagnostic Interview for Genetic Studies: validity and reliability of the Croatian version.

OBJECTIVE: To test the validity and reliability of the Diagnostic Interview for Genetic Studies (DIGS) in patients with mental illness in Croatia. MATERIALS AND METHODS: Following translation, back-translation, and pilot testing, the Croatian version of DIGS (CRO-DIGS) was administered to a total of 150 inpatients and outpatients diagnosed at the Clinical Hospital in Split with bipolar and major depressive disorder (n=56), schizophrenia and schizoaffective disorder (n=62), and alcohol dependence or use disorders (n=32). Initial testing was performed independently by one interviewer and one observer blinded to the diagnosis, and a retest was performed after 8 weeks by a third examiner. RESULTS: The validity of CRO-DIGS was high (κ=0.916), with an excellent inter-rater (κ=0.824) reliability, especially for bipolar disorder (κ=0.956). Following an 8 week test-retest interval, the reliability for all diagnoses was found to be excellent (κ=0.843). CONCLUSION: Our study has shown excellent validity and reliability of the Croatian version of DIGS, making it a promising instrument to assess mental illness of patients. The development of a valid and reliable diagnostic tool such as the CRO-DIGS will considerably advance the scientific communities' ability to carry out genetic studies of psychiatric illness in the region.

Single treatment of low-risk basal cell carcinomas with pulsed dye laser-mediated photodynamic therapy (PDL-PDT) compared with photodynamic therapy (PDT): A controlled, investigator-blinded, intra-individual prospective study.

BACKGROUND AND OBJECTIVE: To compare a single treatment of PDL-PDT with PDT for BCCs in terms of efficacy, aesthetic outcome, and pain in patients with multiple BCCs. STUDY DESIGN/MATERIALS AND METHODS: A prospective, controlled, intra-individual, investigator-blinded study was conducted on 15 patients with 62 BCCs. The BCCs on an individual patient were divided into two similarly-sized groups, and treated with PDT (630nm LED light source, fluence rate=30mW/cm2, total dose of 150J/cm2) and 585 nm-PDL-PDT (spot size=7mm, fluence=10J/cm2, pulse duration=10ms, 10% overlap, three passes, and cooling). Primary outcomes were complete BCC regression at months 3 and 12. Secondary outcomes were pain immediately after treatment, and aesthetic outcome evaluated by a blinded investigator. RESULTS: No significant difference was found in the therapeutic effect between the two treatments (P=0.285). Complete regression of BCCs at 3-months follow-up occurred in 79% of the PDT treated area and 74% of the PDL-PDT area. At month 12, complete regression using PDT was 75% (95% confidence interval (CI) 0.55-0.89) compared to 59% (95% CI 0.41-0.75) for the PDL-PDT treated areas. Both treatments had low mean pain scores: 1.7 for PDT and 2.6 for PDL-PDT (P=0.049) and the aesthetic appearance was similar (P=0.763). CONCLUSION: A single treatment with three passes of PDL-PDT is effective in clearing BCCs, but the recurrence rate is higher than in case of conventional PDT. PDL-PDT is associated with low treatment related pain, has similar cosmetic advantages as PDT but it requires less treatment time.

Brain abscess due to Aggregatibacter aphrophilus and Bacteroides uniformis.

OBJECTIVE: The aim of this report was to describe the occurrence of a bacterial brain abscess in a healthy individual, without any predisposing condition. CASE REPORT: A thirteen-year old boy was admitted to the Department of Neurosurgery after the onset of vomiting, headache and dizziness. A neurological deficit was detected during the physical examination so urgent magnetic resonance imaging of the brain was performed, revealing an intrahemispheric, right positioned solitary expansive mass with ring enhancement. Purulent material was obtained during osteoplastic craniotomy with total extirpation of the brain abscess. Aggregatibacter aphrophilus and Bacteroides uniformis were isolated. The patient's general condition improved and the neurological deficit subsided as a result of the prompt recognition and treatment of this life threatening condition. CONCLUSION: To achieve a favourable clinical outcome, prompt recognition and surgical treatment of a brain abscess are of primary importance,followed by administration of appropriate antimicrobial therapy. To our best knowledge, this is the first report of this combination of microorganisms as the cause of a brain abscess.

Methicillin-resistant Staphylococcus aureus in North-east Croatia.

OBJECTIVE: The aim of this 5-year study was to determine the frequency and antibiotic susceptibility of methicillin-resistant Staphylococcus aureus (MRSA)-related infections at Osijek Clinical Hospital. MATERIALS AND METHODS: A total of 1987 staphylococci-infected clinical isolates were collected and analysed at the Microbiology Department of the Public Health Institute of Osijek-Baranja County. RESULTS: Between 2008 and 2012, the average rate of MRSA-related infections in staphylococci-infected patients was 27.4%. The proportion of MRSA-related infections on all Staphylococcus aureus (S. aureus) isolates from clinical specimens showed a decreasing trend, from 32.6% in 2008 to 25.5% in 2012. MRSA-related infections were mostly detected in wound swabs (50.6%) and aspirates (28.8%) of patients hospitalized in the surgical (49.8%) and intensive care units (27.9%). MRSA-related infection showed an increase compared to S. aureus-infections in samples of wounds and aspirates in 2011 and 2012 (57.9%/34.9% and 35.2%/16.3%, respectively). The majority of strains of MRSA-related infections were resistant to several antibiotics, including erythromycin and clindamycin, where susceptibility were less than 10%. All MRSA isolates were susceptible to vancomycin, teicoplanin and linezolid. Therefore, antibiotic therapies for MRSA infections include vancomycin, teicoplanin and linezolid, but microbiological diagnostics need to be performed in order to know when the use of glycopeptides and oxazolidinones is indicated. CONCLUSION: Our results suggest that appropriate prevention measures, combined with the more rational use of antibiotics are crucial to reduce the spread of MRSA-related infection in healthcare settings. Further monitoring is necessary of the incidence and antibiotic susceptibility of MRSA-related infections in our community.

Polymorphisms of Toll-like receptors 2 and 4 in chronically infected hepatitis C patients from north-east Croatia.

Chronic infection with hepatitis C virus (HCV) is caused by an inadequate immune response. Experimental data suggest that the impaired activation of Toll-like receptors (TLRs) 2 and 4 contributes to chronic infection. We assessed the distribution of three single-nucleotide polymorphisms (SNPs) in the TLR2 (Arg753Gln) and TLR4 (Asp299Gly/Thr399Ile) genes in individuals from north-east Croatia and their effect on the outcome of antiviral therapy. The study consisted of 60 chronically infected patients and 40 healthy subjects. TLR polymorphisms were determined by the PCR-based melting curve analysis. HCV genotyping was performed using the Linear Array Hepatitis C Virus Genotyping Test. Thirty-three patients were treated with standard interferon and ribavirin therapy, and their viral load was evaluated at weeks 28 and 53 after the beginning of therapy. The majority of chronic infections were caused by genotype 1 (77%), followed by genotypes 3 (15%) and 4 (7%). Patients with genotype 1 had higher viral loads than patients infected with other genotypes (P = 0.0428). Healthy individuals and patients with chronic infection had similar frequencies of TLR2-Arg753Gln and TLR4-Asp299Gly/Thr399Ile SNPs. Heterozygous and homozygous TLR4-Asp299Gly/Thr399Ile polymorphisms correlated with higher viral loads and delayed responses to antiviral therapy. We have provided the first evidence that TLR4 polymorphisms influence the success of antiviral therapy in our region. This suggests that therapeutic strategies should be adjusted not only according to HCV genotype but also to individual TLR polymorphism(s).

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.

Most common HCV genotypes in patients from north-eastern Croatia.

OBJECTIVE: The aims of this study were to determine the HCV-RNA viral load, genotype distribution, risk factors and symptoms of HCVRNA positive viral load in HCV antibody-positive patients from north-eastern Croatia. MATERIALS AND METHODS: From January 2009 to December 2011, 203 HCV antibody- positive patients (130 men and 73 women; median age 44.5 years) were analyzed for HCV-RNA by the COBAS TaqMan HCV test and genotyped by the Linear Array HCV Genotyping test (both from Roche). All patients completed a structured questionnaire about risk factors and symptoms. RESULTS: The HCV-RNA percentage was 61.1% and was similar for men and women. The HCV-RNA viral load increased with age: while 55% of 20-50 year old patients were HCV-RNA positive, 73% of patients >50 years were positive (p=0.021). Genotype 1 was the most prevalent genotype (79.8%), followed by 3 (12.9%), 4 (6.5%), and 2 (0.8%); genotypes 5 and 6 were not determined. Patients with genotype 1 (median, 50 years) were older than patients with 3 (median, 33.5 years) or 4 (median, 38 years). The blood transfusions performed in Croatian hospitals before 1993 was significantly associated with HCV-RNA positive viral load (p<0.05). CONCLUSION: These data indicated an elevated prevalence of genotype 1 in elderly HCV-RNA positive patients and it may continue to rise. Using RNA-based detection in HCV positive-antibody patients would allow early detection of HCV in the acute stage of HCV disease and the increased risk of HCV genotyperelated treatment failure.

Matrix metalloproteinases and E-cadherin immunoreactivity in different basal cell carcinoma histological types.

The immunohistochemical staining of matrix metalloproteinases (MMPs) and E-cadherin in tumor epithelial and stromal cells was analyzed in a group of solid, superficial spreading and cystic tumors and in a group of morpheaform and recurrent basal cell carcinomas (BCC) in order to determine whether any of these factors possibly contribute to tumor therapy resistance. Tumor tissues of 64 patients were obtained by complete excisional or curettage biopsy of BCC and these were immunohistochemically stained for MMP-1, MMP-2, MMP-9, MMP-13 and E-cadherin. In the morpheaform and recurrent BCC, MMP-9 expression significantly increased in the stroma, while E-cadherin expression was negative in epithelial cells. Odds ratio for development of morpheaform and recurrent BCC was 6.2 for positive MMP-1 immunostaining in epithelial tumor cells, 5.8 for positive MMP-9 immunostaining in tumor stroma, 3.2 for positive MMP-13 immunostaining in tumor stroma, and 4.5 for negative E-cadherin in epithelial tumor cells. Our results suggest that MMP-1 immunostaining in tumor cells, MMP-9 expression in stromal cells, and absence of E-cadherin expression are associated with morpheaform and recurrent BCC.

Distribution of genital human papillomavirus (HPV) genotypes in Croatian women with cervical intraepithelial neoplasia (CIN)--a pilot study.

Genital infection with high-risk human papillomavirus (HR HPV) associates with increased risk of developing precancerous lesions, such as cervical intraepithelial neoplasia (CIN). The objective of this pilot study conducted in north-east Croatia was to determine the prevalence of HPV genital infection in women with abnormal cervical cytology and to determine its association with their age and HPV genotype(s). From March 2009 to December 2011, cervical swabs from 100 women were analysed for HR HPV infection (AMPLICOR HPV Test, Roche Diagnostics) and genotyped for high risk (HR), intermediate (IR) and low risk (LR) HPVs (Linear Array HPV Genotyping Test, Roche Diagnostics). The most prevalent HR genotypes in women with CIN were HPV 16 (27.6%), HPV 31 (11.8%), HPV 51 and HPV 52 (10.2% each). The most prevalent IR genotypes were HPV 66 (30%) and HPV 62 (23.3%). The most prevalent LR genotype was HPV 6 (20.3%). Women between 21 and 25 years of age showed the highest rate of HPV infection (44.2%). Moreover, women younger than 35 years showed a significant association (p < 0.01) and positive correlation (r = 0.67; p < 0.05) between HR HPV infection and CIN stages 1 and 2. Multiple HPV infections were found in almost half of the women. This is the first study that analysed the prevalence of genital infection with HR/IR/LR HPVs in women with CIN from north-east Croatia. Despite the preliminary nature of this pilot study, the lower prevalence of some HR HPVs (HPV18) and the higher prevalence of other HR HPVs (HPVs 51, 52 and 31) may imply the necessity for the development of more targeted anti-HPV vaccines or other strategies for more efficient protection against oncogenic HPV infection in women from our region.

Prevalence and genotype distribution of high-risk human papillomavirus (HR HPV) in male genital samples of Osijek-Baranja County.

This is a first cross-sectional study on the prevalence and distribution of HPV infection in asymptomatic, heterosexual men from Osijek-Baranja County, Croatia. Between 2009 and 2011, 330 men tested for sexually transmitted diseases (STDs) were recruited. Their genital swabs were tested for high-risk HPV (HR HPV) infection by the AMPLICOR HPV test and further genotyped by the Linear Array HPV Genotyping Test (both by Roche). Infection with a single HR HPV was detected in almost one third of men (39%) whereas multiple HPV types, in more than a half of HR HPV-positive men (61%). The highest HR HPV prevalence was detected in those younger than 20 (37.5%) and lowest in 31-35 year old men (27.8%). The most common genotypes were HPV 6 (24%), 16 (17.8%), 51 (9%), 52 (6%), 35, 55, 66, 84 (each 5%), 31, 62 (each 4%), 39, 58, 59, 83 (each 2.5%), and finally 56, 18, 53, and 54 (each 1.3%). Having more than one sexual partner per year was significantly associated with HR HPV infection in age group between 26 and 30 years (p = 0.001). Due to the high prevalence of HR HPV infection in men of this County and its risk of transmission to women, we recommend more public awareness about this particular STD and initiating vaccination programs of young men and women.

Distribution of Chlamydia trachomatis serotypes in clinical urogenital samples from north-eastern Croatia.

The purpose of this study was to determine prevalence of Chlamydia trachomatis (Ct) urogenital infection and its serotype distribution from clinical samples in north-eastern Croatia. During a 3-year period, 2,379 urogenital samples were analyzed by real-time polymerase chain reaction (A group), while 4,846 genital swabs were analyzed by direct fluorescent antibody test (B group). 132 Ct positive specimens were genotyped by omp1 gene sequencing. The prevalence rate of Ct was 3.2 % in A and 1 % in B group. The most prevalent chlamydial genotype was E (44 %), followed by F (33 %), K (11.5 %), G (8 %), J/UW (5.3 %), D-IC (4.4 %), D-B120 (1.8 %), and B/IU, J/IU, Ia/IU (0.9 % each) serotypes. Single-nucleotide polymorphisms (SNPs) of omp1 gene were detected in E, K, and G serotypes. Some of these SNPs (C/T at position 272 and G/A at position 813 in E strain; C/T at position 884 in D strain) might represent novel omp1 variants.

Heavy metal and bacterial pollution of the Sava River in Serbia.

The aim of this study was to establish microbial and heavy metal pollution of the Sava River at three locations close to industry and urban areas (Sabac, Obrenovac, Beograd) in Serbia. Heavy metal analysis included Cu, Zn, Pb, and Cd in the river water and sediment samples. Using the microbiological analysis we tried to establish the effectiveness of total coliforms, faecal coliforms and Escherichia coli in detecting pollution of surface waters. We found that E. coli levels steadily increased downstream from Sabac (location 1; 2100 MPN per 100 mL) to Belgrade (location 3; 10000 MPN per 100 mL). To prevent bacterial contamination, it is necessary to reduce the discharge of wastewater with faecal matters near highly populated towns. Heavy metal levels in sediments correlated with those in the river water. Fluctuations attributed mainly to anthropogenic sources were not high. These results point to acceptable anthropogenic contribution to heavy metal content in the Sava River and to low environmental risk.

Impact of restricted amoxicillin/clavulanic acid use on Escherichia coli resistance--antibiotic DU90% profiles with bacterial resistance rates: a visual presentation.

High use of amoxicillin/clavulanic acid (AMC) at the University Hospital Osijek (Croatia) contributed to high rates of resistance in Enterobacteriaceae, in particular Escherichia coli (50%). Thus, in order to decrease bacterial resistance, AMC use was restricted. We present results of the restriction on resistance amongst antibiotics accounting for 90% of antibiotic use [drug utilisation 90% (DU90%)]. Data were analysed on antibiotic use and microbiological susceptibility of E. coli during two 9-month periods, before and after the restriction of AMC use. Drug use was presented as numbers of defined daily doses (DDDs) and DDDs/100 bed-days. Resistance of E. coli to antibiotics was presented as percentages of isolated strains in the DU90% segment. Use of AMC was 16 DDDs/100 bed-days or 30% of all antibiotics before the intervention. Use of AMC fell to 2 DDDs/100 bed-days or 4% after the intervention, and resistance of E. coli fell from 37% to 11%. In conclusion, restricted use of AMC resulted in a significant decrease of E. coli resistance. DU90% resistance profiles are simple and useful tools in highlighting problems in antibiotic use and resistance but may also be useful in long-term follow-up of antibiotic policy.

Effect of aminglycoside administration on the occurrence and multiplication of resistant bacteria.

In the prospective study the susceptibility of 41 Escherichia coli strains and 55 Pseudomonas aeruginosa strains to gentamicin, netilmicin and amikacin was tested at a 2-year interval (period I April 1998 to March 1999, and period II April to July 2001). Genotyping was performed by pulsed-field gel electrophoresis, and a clone based on 80% or 90% similarity was determined for each of the study bacteria. In 24 (32.0%) clones, strains showed no variation over 2-year interval, supporting the hypothesis on a priori susceptible strains. Transformation from susceptibility in period I to resistance in period II was demonstrated in 5 (6.7%) clones, a pattern consistent with the concept of bacterial development of resistance under the influence of antibiotics. However, there were 10 (13.3%) clones whose strains exhibited an inverse pattern. Accordingly, two-way transformation of susceptibility took place during the study period. The utilization of the study aminoglycosides had no major impact on the variation of microbial susceptibility. Changes in microbial susceptibility were found to follow some regular patterns, which were not influenced by the study aminoglycosides. Two phenomena were observed: (i) there were stable clones that did not develop resistance in spite of selective antibiotic challenge; and (ii) changes of susceptibility in isolated bacteria from both inpatient and outpatient strains of the same clone were two-way and reversible.