[Dip-slides for culturing urine in general practice]. / Urindyppekultur i allmennpraksis.

BACKGROUND: A consensus meeting at the Norwegian Institute of Public Health decided to change the limits for significant bacteriuria (used in microbiology laboratories) from 104 to 103 colony-forming units per ml. Such a low threshold value is difficult to read on dip-slides; NOKLUS (Norwegian quality improvement of laboratories in primary care) therefore wished to review the use of dip-slides in general practice. MATERIAL AND METHODS: The article is based on literature retrieved through a non-systematic search in PubMed and on the authors' experience and research in the field. RESULTS: Escherichia coli (E coli) is the most common agent in both lower and upper urinary tract infections, and in asymptomatic bacteriuria in pregnant women. In most infections, and particularly in upper urinary tract infections, bacterial concentrations are at least 104 colony-forming units per ml of urine in monocultures. Dip-slides should be the preferred transport medium when transport takes more than two days (because the number of colonies is not affected), otherwise urine samples with boric acid as a preservative are preferred. INTERPRETATION: Dip-slides with E coli-agar may provide important information on complicated (especially upper) urinary tract infections and when examining pregnant women for asymptomatic bacteriuria. Dip-slides should not be used in uncomplicated cystitis. Medical practices using dip-slides must achieve and maintain sufficient expertise, and participate in an external quality assurance system. Proper sampling and handling of urine is even more important than before because of the lower threshold for significant bacteriuria.

Antibiotic susceptibility of blood culture isolates of anaerobic bacteria at a Norwegian university hospital.

In the present study the susceptibility of 200 blood culture isolates of anaerobic bacteria to benzylpenicillin, clindamycin, metronidazole, imipenem and piperacillin-tazobactam was examined. Metronidazole, imipenem, and piperacillin-tazobactam showed the highest activity, with 98.5% of the isolates being fully susceptible to either agent. A high rate of reduced susceptibility to clindamycin among both Bacteroides spp. (37%) and Clostridium spp. (28%) was found. Almost all Bacteroides isolates were resistant to penicillin, and only 60% of Prevotella spp. were susceptible to this agent. The antibiotic susceptibility of anaerobic bacteria in Norway should be surveyed regularly.

Candidemia in Norway (1991 to 2003): results from a nationwide study.

A long-term, nationwide prospective candidemia study has been ongoing in Norway since 1991. All medical microbiological laboratories in the country have participated. During the period 1991 to 2003 a total of 1,393 episodes of candidemia occurred in 1,348 patients. The incidence of candidemia episodes per 100,000 inhabitants increased from approximately 2 episodes in the early 1990s to 3 episodes in 2001 to 2003. The average annual incidences varied markedly between the age groups. The incidence was high in patients aged < 1 year and in patients aged > or = 70 years. In patients > or = 80 years of age, the incidence has increased during the last 3 years from an annual average of 6.5 to 15.6 cases/100,000 inhabitants in 2003. Four Candida species (C. albicans [70%], C. glabrata [13%], C. tropicalis [7%], and C. parapsilosis [6%]) accounted for 95.5% of the isolates. The species distribution has been constant during the 13-year study period. The distribution of the most important species varied with the age of the patient. In patients < 1 year of age, the majority of episodes were caused by C. albicans (91%). The occurrence of C. glabrata increased with age. In patients > or = 80 years of age, approximately 1/3 of all episodes were due to this species. All C. albicans strains were susceptible to fluconazole. The percentage of yeast isolates with decreased susceptibility to fluconazole (MICs > or = 16 microg/ml) was 10.7% during the first period of this study (1991 to 1996) and 11.7% during the second period (1997 to 2003).

[Quality assessment of urine dip-slides in primary care]. / Vurdering av urindyppekultur i primaerhelsetjenesten.

BACKGROUND: In Norway, approximately 35% of surgery laboratories use dip-slides to assess bacteriuria. From 2000 to 2004 the Norwegian centre for quality assurance in primary health care (NOKLUS) has evaluated how office laboratories assess urine dip-slides. MATERIAL AND METHODS: Once a year participants receive inoculated and incubated dip-slides to read and report to NOKLUS. Target values are determined from assessments in four large microbiological laboratories. RESULTS: Knowledge of reading dip-slides is insufficient. Only 40% of the participants in the quality assessment program evaluate whether growth is gram-negative or gram-positive, or take into account whether the growth is mono-bacterial or mixed. Many participants send the dip-slide to microbiological laboratories for evaluation whenever growth is significant, also when the growth is mixed. INTERPRETATION: The programme shows that Norwegian office laboratories do not use all the information they can get from the dip-slide. There is a need for guidelines on this topic in general practice.

A multi-centre prospective study of febrile neutropenia in Norway: microbiological findings and antimicrobial susceptibility.

The urgent need to treat presumptive bacterial or fungal infections in neutropenic patients has meant that initial therapy is empiric and based on the pathogens most likely to be responsible, and drug resistance. The traditional empirical treatment in Norway has been penicillin G and an aminoglycoside, and this combination has been criticized over recent y. We wished to analyse the microbiological spectrum and susceptibility patterns of pathogens causing bacteraemia in febrile neutropenic patients. This was a prospective multicentre study. During the study period of 2 y, a total of 282 episodes of fever involving 243 neutropenic patients was observed. In 34% of episodes bacteraemia was documented. Overall, 40% of the episodes were caused by Gram-positive organisms, 41% by Gram-negative organisms and 19% were polymicrobial. The most frequently isolated bacteria were Escherichia coli (25.6%), a- and non-haemolytic streptococci (15.6%), coagulase-negative staphylococci (12.4%) and Klebsiella spp. (7.4%). None of the Gram-negative isolates was resistant to gentamicin, meropenem, ceftazidime or ciprofloxacin. Only 5 coagulase-negative staphylococci isolates were resistant to both penicillin G and aminoglycoside. The overall mortality rate was 7%, and 1.2% due to confirmed bacteraemic infection.

Surveillance of antimicrobial resistance at a tertiary hospital in Tanzania.

BACKGROUND: Antimicrobial resistance is particularly harmful to infectious disease management in low-income countries since expensive second-line drugs are not readily available. The objective of this study was to implement and evaluate a computerized system for surveillance of antimicrobial resistance at a tertiary hospital in Tanzania. METHODS: A computerized surveillance system for antimicrobial susceptibility (WHONET) was implemented at the national referral hospital in Tanzania in 1998. The antimicrobial susceptibilities of all clinical bacterial isolates received during an 18 months' period were recorded and analyzed. RESULTS: The surveillance system was successfully implemented at the hospital. This activity increased the focus on antimicrobial resistance issues and on laboratory quality assurance issues. The study identified specific nosocomial problems in the hospital and led to the initiation of other prospective studies on prevalence and antimicrobial susceptibility of bacterial infections. Furthermore, the study provided useful data on antimicrobial patterns in bacterial isolates from the hospital. Gram-negative bacteria displayed high rates of resistance to common inexpensive antibiotics such as ampicillin, tetracycline and trimethoprim-sulfamethoxazole, leaving fluoroquinolones as the only reliable oral drugs against common Gram-negative bacilli. Gentamicin and third generation cephalosporins remain useful for parenteral therapy. CONCLUSION: The surveillance system is a low-cost tool to generate valuable information on antimicrobial resistance, which can be used to prepare locally applicable recommendations on antimicrobial use. The system pinpoints relevant nosocomial problems and can be used to efficiently plan further research. The surveillance system also functions as a quality assurance tool, bringing attention to methodological issues in identification and susceptibility testing.

Susceptibility to quinupristin-dalfopristin and linezolid in 839 clinical isolates of Gram-positive cocci from Norway.

A total of 839 clinical isolates of Gram-positive cocci from Norway including Staphylococcus aureus (n = 214), coagulase negative Staphylococcus spp. (n = 100), Streptococcus pyogenes (n = 99), Streptococcus agalactiae (n = 80), Streptococcus pneumoniae (n = 127), Streptococcus spp. viridans group (n = 70), Enterococcus faecalis (n = 75), and Enterococcus faecium (n = 74), were tested by E-test for susceptibility to a range of antimicrobials including the novel antibiotics quinupristin-dalfopristin and linezolid. Subgroups of oxacillin resistant S. aureus and coagulase negative Staphylococcus spp., penicillin non-susceptible S. pneumoniae and vancomycin resistant Enterococcus spp. were specifically included as they are the intended targets for these new drugs. All isolates were susceptible to linezolid (MIC5o and MIC9o 0.25-2.0 mg/l, MIC range 0.12-2 mg/l). Staphylococcal and streptococcal isolates were also susceptible to quinupristin-dalfopristin except for some intermediately susceptible viridans group isolates (MIC54, and MIC90 0.25-2 mg/l, MIC range 0.125-2 mg/l). Enterococcus faecium (MIC90 = 4.0 mg/l) and Enterococcus faecalis (MIC50 = 8.0 mg/l, MIC90 > or = 32 mg/l) were less susceptible to this substance. There was no linkage between reduced susceptibility to linezolid or quinupristin-dalfopristin and resistance to other classes of antimicrobials. The study demonstrated a high prevalence of in vitro susceptibility to linezolid and quinupristin-dalfopristin, which is necessary for their use in the treatment of infections with resistant Gram-positive pathogens. The results were used to evaluate the appropriateness of breakpoints and to define a baseline for monitoring possible future emergence of resistance to quinupristin-dalfopristin and linezolid in Norway.

Comparative analysis of amplified fragment length polymorphism and pulsed field gel electrophoresis in a hospital outbreak and subsequent endemicity of ampicillin-resistant Enterococcus faecium.

Reliable molecular methods for determination of relatedness between bacterial isolates have become increasingly important to evaluate outbreaks and endemic situations with nosocomial pathogens. In the present study Simpson's index of diversity with calculated confidence intervals was used to compare amplified fragment length polymorphism (AFLP) and pulsed field gel electrophoresis (PFGE) analysis of a hospital outbreak of ampicillin-resistant Enterococcus faecium and subsequent endemicity. The outbreak, in a Norwegian tertiary hospital, of infections caused by these enterococci started in 1995 and increased in 1996 after which the situation turned endemic. The purpose of this study was to compare the two methods in this setting and to determine the length of time during an outbreak that these methods are sufficiently valid to be of value for hospital infection control efforts. One hundred and sixty clinical isolates from urine specimens collected during the period 1995-1999 were included. The findings indicate that PFGE and AFLP are equally discriminative and could in this setting be used for typing purposes over the whole 5-year period.

Generalized symptoms in adult women with acute uncomplicated lower urinary tract infection: an observational study.

Several generalized symptoms in acute lower urinary tract infection (UTI) have previously been identified in a qualitative study. The aim of the present study was to explore the frequency and distribution of generalized symptoms in adult women with acute uncomplicated lower UTI in general practice. A total of 398 women aged 18-87 years consulting for acute dysuria and/or urinary frequency were enrolled in an observational study and filled in a structured symptom questionnaire. A total of 252 of these had bacteriuria (>or= 10(5) uropathogens/mL). Generalized symptoms occurred frequently: feeling unwell 68%, week and tired 67%, irritable and restless 53%, and hot 52%. Other symptoms were voiding-related symptoms (dysuria 90%, urinary frequency 93%, urge 80%) and local, constant symptoms (pressure in the genital area 73%, suprapubic discomfort 68%). Factor analysis revealed 2 main components of cystitic symptoms: "feeling out of sorts" (generalized symptoms) predominantly found among women aged 50-65 years, and the "distressed bladder" (voiding-related and local, constant symptoms) most often in the group aged 18-35 years. No differences in frequency or degree of symptoms were related to the presence of bacteriuria. In conclusion, generalized symptoms of feeling out of sorts are frequent in adult women with acute uncomplicated lower UTI, and equally frequent in all ages whether the patient shows bacteriuria or not.

[Urinary tract pathogens in uncomplicated lower urinary tract infections in women in Norway]. / Urinveispatogene bakterier ved ukomplisert nedre urinveisinfeksjon hos kvinner.

BACKGROUND: We wanted to investigate the antimicrobial susceptibility of urinary tract pathogens in uncomplicated lower urinary tract infections in adult women in Norway. MATERIAL AND METHODS: Urine samples from 312 adult women with symptoms of uncomplicated urinary tract infections from eight general practices were included. RESULTS: Significant bacteriuria was found in 187 samples (60%). E coli was isolated from 153 (82%) of these samples. Other isolated uropathogens were S saprophyticus 18 (10%), Proteus spp 6 (3%), Klebsiella spp 4 (2%), Enterobacter spp 2 (1%), enterococci 1 (0.5%) and other Gram-positive bacteria 3 (1,5%). No fungi were isolated. Of the E coli isolates, 1 %, 1 % and 9 % were resistant to nitrofurantoin, mecillinam and trimetoprim respectively. All S saprophyticus isolates were sensitive to nitrofurantoin and trimetoprim. INTERPRETATION: Antibiotic resistance of urinary tract pathogens causing uncomplicated urinary tract infections in adult women in general practice is still low in Norway.

Factors associated with increased and decreased risk of Campylobacter infection: a prospective case-control study in Norway.

In 1999-2000, a prospective case-control study of sporadic, domestically acquired campylobacteriosis was conducted in three counties in Norway to identify preventable risk factors and potentially protective factors. A total of 212 cases and 422 population controls matched by age, sex, and geographic area were enrolled. In conditional logistic regression analysis, the following factors were found to be independently associated with an increased risk of Campylobacter infection: drinking undisinfected water, eating at barbecues, eating poultry bought raw, having occupational exposure to animals, and eating undercooked pork. The following factors were independently related to a decreased risk: eating mutton, eating raw fruits or berries, and swimming. Results indicated that infection is more likely to occur as a result of cross-contamination from raw poultry products than because of poultry consumption per se. Drinking undisinfected water, reported by 53% of cases, was a leading risk factor in this study. Drinking water may constitute the common reservoir linking infection in humans and animals, including poultry and wild birds. Insight into the ecology of Campylobacter in freshwater ecosystems may be required to understand the epidemiology of campylobacteriosis. The possibility that certain foods confer protection against campylobacteriosis deserves exploration.

The relation between sale of antimicrobial drugs and antibiotic resistance in uropathogens in general practice.

BACKGROUND: Overuse of antimicrobial drugs has resulted in an alarming increase in bacterial resistance in most countries. The relevance for general practice is unknown. OBJECTIVE: To evaluate the impact of the sale of antimicrobial drugs on bacterial resistance as found in uropathogens from general practice. SETTING: General practice in Belgium and Norway. METHODS: Observational study. RESULTS: The sale of antimicrobial drugs indicated for use in the treatment of urinary tract infection was four times higher in Belgium than in Norway (18.5 vs 4.4 DDD/1000 inhabitants/day). The antibiotic resistance reported by microbiological laboratories as valid for general practice was significant higher in Belgium than in Norway (ampicillins (44% vs 27%), co-trimoxazole (28% vs 17%), fluoroquinolones (12% vs 2%) and nitrofurantoin (16% vs 11%, p < 0.0001 for all). However, the antibiotic resistance found in urine samples from dysuric women in general practice was similar (trimethoprim 14% vs 12%, co-trimoxazole 14% vs 11%, nitrofurantoin 7% vs 3%), except in the case of ampicillins (30% vs 19%, p < 0.05). CONCLUSION: The impact of the antimicrobial sale on resistance in uropathogens seems less than expected at the general practice level, even though local microbiological reports mention fairly high antibiotic resistance data. Adapted methods for following-up bacterial resistance evolution in general practice are needed.

Lactobacillus rhamnosus septicaemia in a patient with a graft in the inferior vena cava.

A case of septicaemia that repeatedly showed growth of Lactobacillus rhamnosus in blood cultures is reported. The patient improved after removal of a Goretex patch in the inferior vena cava that was the focus of the infection. Lactobacilli can, in certain settings, be the cause of clinically important infections.

Molecular epidemiological study of Salmonella enterica serovar paratyphi B infections imported from Turkey to Western Norway.

During the summer of 1999, several Norwegian tourists returning from Turkey became ill as a result of Salmonella enterica serovar paratyphi B (S. paratyphi B) infection. We examined the S. paratyphi B isolates from 14 of these patients (10 from blood cultures, 4 from stool specimens) who were admitted to 2 hospitals in Bergen, Norway during August and September 1999. Moreover, during the same period, a laboratory technician working at 1 of these hospitals was admitted with S. paratyphi B septicemia and was included in the study. Using repetitive-sequence-based PCR (rep-PCR) with 2 primer pairs (ERIC and REP), pulsed-field gel electrophoresis and phage typing we found that the laboratory technician was infected with the same S. paratyphi B clone as the 14 tourists. The discriminatory capacity of the rep-PCR method and pulsed-field gel electrophoresis was examined using S. paratyphi B strains from the outbreak and from other geographical locations. We conclude that a combination of rep-PCR with the ERIC primer pair and phage typing was useful in discriminating between the epidemic isolates and epidemiologically unrelated isolates from S. paratyphi B infections and that the laboratory technician was most likely infected while handling patient samples or bacterial cultures from the Turkish tourists.