Contaminated dicloxacillin capsules as the source of an NDM-5/OXA-48-producing Enterobacter hormaechei ST79 outbreak, Denmark and Iceland, 2022 and 2023.

From October 2022 through January 2023, nine patients with NDM-5/OXA-48-carbapenemase-producing Enterobacter hormaechei ST79 were detected in Denmark and subsequently one patient in Iceland. There were no nosocomial links between patients, but they had all been treated with dicloxacillin capsules. An NDM-5/OXA-48-carbapenemase-producing E. hormaechei ST79, identical to patient isolates, was cultured from the surface of dicloxacillin capsules in Denmark, strongly implicating them as the source of the outbreak. Special attention is required to detect the outbreak strain in the microbiology laboratory.

Development of a prognostic model of COVID-19 severity: a population-based cohort study in Iceland.

BACKGROUND: The severity of SARS-CoV-2 infection varies from asymptomatic state to severe respiratory failure and the clinical course is difficult to predict. The aim of the study was to develop a prognostic model to predict the severity of COVID-19 in unvaccinated adults at the time of diagnosis. METHODS: All SARS-CoV-2-positive adults in Iceland were prospectively enrolled into a telehealth service at diagnosis. A multivariable proportional-odds logistic regression model was derived from information obtained during the enrollment interview of those diagnosed between February 27 and December 31, 2020 who met the inclusion criteria. Outcomes were defined on an ordinal scale: (1) no need for escalation of care during follow-up; (2) need for urgent care visit; (3) hospitalization; and (4) admission to intensive care unit (ICU) or death. Missing data were multiply imputed using chained equations and the model was internally validated using bootstrapping techniques. Decision curve analysis was performed. RESULTS: The prognostic model was derived from 4756 SARS-CoV-2-positive persons. In total, 375 (7.9%) only required urgent care visits, 188 (4.0%) were hospitalized and 50 (1.1%) were either admitted to ICU or died due to complications of COVID-19. The model included age, sex, body mass index (BMI), current smoking, underlying conditions, and symptoms and clinical severity score at enrollment. On internal validation, the optimism-corrected Nagelkerke's R2 was 23.4% (95%CI, 22.7-24.2), the C-statistic was 0.793 (95%CI, 0.789-0.797) and the calibration slope was 0.97 (95%CI, 0.96-0.98). Outcome-specific indices were for urgent care visit or worse (calibration intercept -0.04 [95%CI, -0.06 to -0.02], Emax 0.014 [95%CI, 0.008-0.020]), hospitalization or worse (calibration intercept -0.06 [95%CI, -0.12 to -0.03], Emax 0.018 [95%CI, 0.010-0.027]), and ICU admission or death (calibration intercept -0.10 [95%CI, -0.15 to -0.04] and Emax 0.027 [95%CI, 0.013-0.041]). CONCLUSION: Our prognostic model can accurately predict the later need for urgent outpatient evaluation, hospitalization, and ICU admission and death among unvaccinated SARS-CoV-2-positive adults in the general population at the time of diagnosis, using information obtained by telephone interview.

Determining SARS-CoV-2 non-infectivity state-A brief overview.

From the beginning of the COVID-19 pandemic, it has claimed over 6 million lives, and globally the pandemic rages with detrimental consequences, with the emergence of new more infectious and possibly virulent variants. A clinical obstacle in this battle has been to determine when an infected individual has reached a non-infectious state. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) can be transmitted under diverse circumstances, and various rules and regulations, along with different testing methods, have been applied in an attempt to confine the transmission. However, that has proven to be a difficult task. In this review, we take together recently published data on infectivity and transmission of SARS-CoV-2 and have combined it with the clinical experience that physicians in Iceland have accumulated from the pandemic. In addition, we suggest guidelines for determining when patients with COVID-19 reach a non-infectious state based on a combination of clinical experience, scientific data, and proficient use of available tests. This review has addressed some of the questions regarding contagiousness and immunity against SARS-CoV-2.

Detailed Multiplex Analysis of SARS-CoV-2 Specific Antibodies in COVID-19 Disease.

A detailed understanding of the antibody response against SARS-CoV-2 is of high importance, especially with the emergence of novel vaccines. A multiplex-based assay, analyzing IgG, IgM, and IgA antibodies against the receptor binding domain (RBD), spike 1 (S1), and nucleocapsid proteins of the SARS-CoV-2 virus was set up. The multiplex-based analysis was calibrated against the Elecsys® Anti-SARS-CoV-2 assay on a Roche Cobas® instrument, using positive and negative samples. The calibration of the multiplex based assay yielded a sensitivity of 100% and a specificity of 97.7%. SARS-CoV-2 specific antibody levels were analyzed by multiplex in 251 samples from 221 patients. A significant increase in all antibody types (IgM, IgG, and IgA) against RBD was observed between the first and the third weeks of disease. Additionally, the S1 IgG antibody response increased significantly between weeks 1, 2, and 3 of disease. Class switching appeared to occur earlier for IgA than for IgG. Patients requiring hospital admission and intensive care had higher levels of SARS-CoV-2 specific IgA levels than outpatients. These findings describe the initial antibody response during the first weeks of disease and demonstrate the importance of analyzing different antibody isotypes against multiple antigens and include IgA when examining the immunological response to COVID-19.

Low Risk of Central Line-associated Bloodstream Infections in Pediatric Hematology/Oncology Patients.

BACKGROUND: Central venous lines (CVLs) are essential for standard care of pediatric hematology/oncology patients providing safe administration of cytotoxic drugs and pain-free blood sampling. Central line-associated bloodstream infections (CLABSIs) cause significant morbidity. This study describes the epidemiology, microbiology, and risk factors for CLABSI in all children with malignancies in Iceland. METHODS: All children that were diagnosed with malignancy in Iceland and received a CVL during 2008-2017 were included in the study. Characteristics of CVLs and patients were registered, information on risk factors, and microbiology was collected. International standards were used for CLABSI definition. RESULTS: One hundred forty-three CVLs were placed in 94 children. Acute lymphoblastic leukemia was the most common underlying disease (31/94). Median age was 7 years. Implantable ports were the most commonly placed CVLs (82/143, 57%), tunneled lines were 39 (27%). Overall CLABSI rate was 0.24 infections/1000 line-days (14 episodes in 58,830 line-days), with little fluctuations. No CLABSI episodes occurred for 4 consecutive years (2012-2015). Staphylococci (of which 7 Staphylococcus aureus) were the cause of 10/14 episodes. Nine CLABSI episodes led to line removal, but no deaths were linked to CLABSIs. CONCLUSION: We report very low CLABSI rates over a 9-year period at our hospital, with 4 consecutive CLABSI-free years. Even with the addition of episodes of possible CLABSI, rates were still very low and lower than most published reports.

Clinical spectrum of coronavirus disease 2019 in Iceland: population based cohort study.

OBJECTIVE: To characterise the symptoms of coronavirus disease 2019 (covid-19). DESIGN: Population based cohort study. SETTING: Iceland. PARTICIPANTS: All individuals who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by reverse transcription polymerase chain reaction (RT-PCR) between 17 March and 30 April 2020. Cases were identified by three testing strategies: targeted testing guided by clinical suspicion, open invitation population screening based on self referral, and random population screening. All identified cases were enrolled in a telehealth monitoring service, and symptoms were systematically monitored from diagnosis to recovery. MAIN OUTCOME MEASURES: Occurrence of one or more of 19 predefined symptoms during follow-up. RESULTS: Among 1564 people positive for SARS-CoV-2, the most common presenting symptoms were myalgia (55%), headache (51%), and non-productive cough (49%). At the time of diagnosis, 83 (5.3%) individuals reported no symptoms, of whom 49 (59%) remained asymptomatic during follow-up. At diagnosis, 216 (14%) and 349 (22%) people did not meet the case definition of the Centers for Disease Control and Prevention and the World Health Organization, respectively. Most (67%) of the SARS-CoV-2-positive patients had mild symptoms throughout the course of their disease. CONCLUSION: In the setting of broad access to RT-PCR testing, most SARS-CoV-2-positive people were found to have mild symptoms. Fever and dyspnoea were less common than previously reported. A substantial proportion of SARS-CoV-2-positive people did not meet recommended case definitions at the time of diagnosis.

Infections and outcomes after cardiac surgery-The impact of outbreaks traced to transesophageal echocardiography probes.

BACKGROUND: Infections are a frequent complication of cardiac surgery. The intraoperative use of transesophageal echocardiography (TEE) may be an underrecognized risk factor for post-operative infections. The aim of this study was to investigate infection rates and outcomes after cardiac surgery in a nationwide cohort, especially in relation to periods where surface damaged TEE probes were used. METHODS: This was a retrospective, observational study at Landspitali University Hospital. All consecutive cardiac surgery patients from 1 January 2013 to 31 December 2017 were included. Patients' charts were reviewed for evidence of infection, post-operative complications or death. RESULTS: During the study period, 973 patients underwent cardiac surgery at Landspitali and 198 (20.3%) developed a post-operative infection. The most common infections were: Pneumonia (9.1%), superficial surgical site (5.7%), bloodstream (2.8%) and deep sternal wound (1.7%). Risk factors for developing an infection included: The duration of procedure, age, insulin-dependent diabetes, EuroScore II, reoperation for bleeding and an operation in a period with a surface damaged TEE probe in use. Twenty-two patients were infected with a multidrug resistant strain of Klebsiella oxytoca, 10 patients with Pseudomonas aeruginosa and two patients developed endocarditis with Enterococcus faecalis. All three pathogens were cultured from the TEE probe in use at respective time, after decontamination. The 30-day mortality rate in the patient cohort was 3.2%. CONCLUSIONS: The intraoperative use of surface damaged TEE probes caused two serious infection outbreaks in patients after cardiac surgery. TEE probes need careful visual inspection during decontamination and probe sheaths are recommended.

[Lyme disease in Iceland - Epidemiology from 2011 to 2015].

INTRODUCTION: Lyme disease is caused by an infection with Borrelia burgdorferi sensu latu (B. burgdorferi sl.) which is carried by Ixodes ticks. The disease has not been considered to be endemic in Iceland and no cases of Icelandic origin have been published. The epidemiology of Lyme disease in Iceland has never been studied. The objective of this study was to provide basic epidemiological information about Lyme disease in Iceland. MATERIAL AND METHODS: Included in the study were all pa--tients who had a measurement of serum antibodies against B. burgdorferi sl. or were diagnosed with Lyme disease (ICD-10, A69.2) at Landspítali University Hospital in Iceland from 2011-2015. Clinical data regarding these patients was retrospectively collected from medical records and the database of the Department of clinical microbiology at Landspítali University Hospital. RESULTS: 501 patient had a measurement of serum antibodies against B. burgdorferi sl. and 11 patients were clinically diag-nosed with Lyme disease during the study period. 33 patients fulfilled criteria for a confirmed diagnosis of Lyme disease. 32 (97%) patients had erythema migrans and one (3%) patient had neuroborreliosis. An average of 6.6 cases were diagnosed a year (two cases per 100,000 persons/year). All cases originated abroad. CONCLUSIONS: Lyme disease is rare in Iceland. On average around 6 to 7 cases are diagnosed every year, primarily localised infec-tions presenting as erythema migrans. None of the cases had a definitive Icelandic origin and the yearly number of cases has not been increasing.

ARDS from miliary tuberculosis successfully treated with ECMO.

Tuberculosis is a rare cause of acute respiratory distress syndrome (ARDS) and mortality rates are high in tuberculosis patients that need treatment with mechanical ventilation. Experience of the use of extracorporeal membrane oxygenation (ECMO) in such circumstances is scarce. We report the case of an 18 year old man where prolonged therapy (50 days) with extracorporeal membrane oxygenation (ECMO) allowed extensive lung damage from miliary tuberculosis to heal. The case reflects how challenging the diagnosis of tuberculosis may be and how difficult it is to reach adequate blood levels of anti-tuberculosis drugs while on ECMO. It's also an example of how indications for ECMO have been expanding the last years and that long term ECMO therapy is possible without serious complications.

Pandemic vaccination strategies and influenza severe outcomes during the influenza A(H1N1)pdm09 pandemic and the post-pandemic influenza season: the Nordic experience.

During the 2009/10 influenza A(H1N1)pdm09 pandemic, the five Nordic countries adopted different approaches to pandemic vaccination. We compared pandemic vaccination strategies and severe influenza outcomes, in seasons 2009/10 and 2010/11 in these countries with similar influenza surveillance systems. We calculated the cumulative pandemic vaccination coverage in 2009/10 and cumulative incidence rates of laboratory confirmed A(H1N1)pdm09 infections, intensive care unit (ICU) admissions and deaths in 2009/10 and 2010/11. We estimated incidence risk ratios (IRR) in a Poisson regression model to compare those indicators between Denmark and the other countries. The vaccination coverage was lower in Denmark (6.1%) compared with Finland (48.2%), Iceland (44.1%), Norway (41.3%) and Sweden (60.0%). In 2009/10 Denmark had a similar cumulative incidence of A(H1N1)pdm09 ICU admissions and deaths compared with the other countries. In 2010/11 Denmark had a significantly higher cumulative incidence of A(H1N1)pdm09 ICU admissions (IRR: 2.4; 95% confidence interval (CI): 1.9-3.0) and deaths (IRR: 8.3; 95% CI: 5.1-13.5). Compared with Denmark, the other countries had higher pandemic vaccination coverage and experienced less A(H1N1)pdm09-related severe outcomes in 2010/11. Pandemic vaccination may have had an impact on severe influenza outcomes in the post-pandemic season. Surveillance of severe outcomes may be used to compare the impact of influenza between seasons and support different vaccination strategies.

Low mortality of Staphylococcus aureus bacteremia in Icelandic children: nationwide study on incidence and outcome.

BACKGROUND: Staphylococcus aureus is a major cause of blood stream infections, but population-based studies on pediatric S. aureus bacteremia (SAB) are sparse. The objective of the study was to evaluate the incidence and mortality of SAB in Icelandic children over time, and to assess the proportions of nosocomial and health-care-associated infections. METHODS: Children <18 years with positive blood cultures for S. aureus from January 1995 through December 2011 were identified retrospectively at the clinical microbiology laboratories performing blood cultures in Iceland. Clinical data were collected from medical records. RESULTS: In total, 140 children had 146 distinct episodes of SAB. Bacteremia-related mortality was 0.7% (1/146), all-cause 30-day mortality, 1.4% (2/146), and 1-year mortality, 3.6% (5/140). The annual incidence of SAB was 10.9/100,000 children, decreasing by 36% from 13.1/100,000 in 1995-2003 to 8.4/100,000 in 2004-2011 (P < 0.001). At the same time the annual number of blood cultures analyzed at the main study site decreased from 1529 to 1143 (25%). SAB incidence was highest in infants (<1 year), 58.8/100,000. Of 146 episodes 50 (34%) were nosocomial, 21 (14%) health-care associated and 75 (51%) community acquired. No methicillin-resistant S. aureus isolate was identified. CONCLUSIONS: In this nationwide study on pediatric SAB, the case fatality ratio was very low. A decreasing incidence was seen, possibly related to fewer blood cultures being collected. Nosocomial and health-care-associated infections accounted for 50% of the cases. The findings provide useful information on the epidemiology and outcome of SAB in children.

The role and utilisation of public health evaluations in Europe: a case study of national hand hygiene campaigns.

BACKGROUND: Evaluations are essential to judge the success of public health programmes. In Europe, the proportion of public health programmes that undergo evaluation remains unclear. The European Centre for Disease Prevention and Control sought to determine the frequency of evaluations amongst European national public health programmes by using national hand hygiene campaigns as an example of intervention. METHODS: A cohort of all national hand hygiene campaigns initiated between 2000 and 2012 was utilised for the analysis. The aim was to collect information about evaluations of hand hygiene campaigns and their frequency. The survey was sent to nominated contact points for healthcare-associated infection surveillance in European Union and European Economic Area Member States. RESULTS: Thirty-six hand hygiene campaigns in 20 countries were performed between 2000 and 2012. Of these, 50% had undergone an evaluation and 55% of those utilised the WHO hand hygiene intervention self-assessment tool. Evaluations utilised a variety of methodologies and indicators in assessing changes in hand hygiene behaviours pre and post intervention. Of the 50% of campaigns that were not evaluated, two thirds reported that both human and financial resource constraints posed significant barriers for the evaluation. CONCLUSION: The study identified an upward trend in the number of hand hygiene campaigns implemented in Europe. It is likely that the availability of the internationally-accepted evaluation methodology developed by the WHO contributed to the evaluation of more hand hygiene campaigns in Europe. Despite this rise, hand hygiene campaigns appear to be under-evaluated. The development of simple, programme-specific, standardised guidelines, evaluation indicators and other evidence-based public health materials could help promote evaluations across all areas of public health.

[Epidemiology of needlesticks at Landspítali University Hospital during the years 1986-2011. A descriptive study]. / Faraldsfrædi stunguóhappa á Landspítalanum á árunum 1986-2011

INTRODUCTION: Needlesticks, bodyfluid exposure and bites (incident) put healthcare workers (HCWs) at risk of hepatitis B, C and HIV particularly if patients are infected (high risk incident). The risk of infection is greatest from bore-hollow needles. The aim of the study was to describe the epidemiology of reported incidents and evaluate underreporting by HCWs at Landspítali University Hospital (LUH). METHODS: A retrospective descriptive study of reported incidents during 1986-2011. The ratio of incidents was calculated according to the HCWs age and profession and distribution by source and wards. The ratio of high risk incidents and vaccination status against HBV at time of incident was determined as well as underreporting during 01.01.2005-31.12.2011. RESULTS: At least 4089 incidents occured during the study period but 3587 were reported and blood samples taken from 2578 patients. Approximately a third of the incidents were associated with non-compliance with standard precaution and 54,7% of needlesticks were associated with bore-hollow needles. Few reports came from physicians and medical students (17,9%). During the study period 50,3% HCWs were vaccinated against HBV at time of incident. High risk incidents were 94 (2.6%), mostly related to hepatitis C (64,9%). Two HCWs became infected with HCV. During 2005-2011 underreporting was estimated to be 28,0%. CONCLUSION: Improved education of standard precaution when handling needles and sharps at LUH may reduce the number of incidents. Introduction of safety-needles and safety-devices may greatly reduce needlesticks as a large number of incidents were associated with hollow needles. Improved HBV vaccination among HCWs and reporting incidents should be encouraged.

Clinical significance of Staphylococcus aureus bacteriuria in a nationwide study of adults with S. aureus bacteraemia.

OBJECTIVES: To evaluate the clinical significance of Staphylococcus aureus bacteriuria (SABU) in adults with S. aureus bacteraemia (SAB). METHODS: All individuals ≥18 years old diagnosed with SAB in Iceland between December 1st 2003 and November 30th 2008 were retrospectively identified. Data was collected from medical records. Concomitant SABU was defined as growth of S. aureus in a urine sample taken within 24 h of the index blood culture. RESULTS: SABU was seen in 27 of 166 (16.3%) SAB patients having urine cultured before administration of antibiotics, but after excluding those with SAB of urinary tract origin SABU was seen in 16 of 152 (10.5%). In this latter cohort SABU was independently associated with having endocarditis (RR 6.68; 95% CI 1.53-17.3) and admission to intensive-care unit (RR 2.84; 95% CI 1.25-4.44), while for having complicated SAB the RR was 1.56 (95% CI 0.96-1.80). No correlation was seen with mortality or relapse rates. CONCLUSIONS: SABU appears to be secondary to SAB in some cases while it is the primary infection causing SAB in others. In patients with SAB of non-urinary tract origin SABU should probably be regarded as distant haematogenous seeding and a marker of deep tissue dissemination, thus affecting general management and treatment duration.

Staphylococcus aureus bacteraemia--Nationwide assessment of treatment adequacy and outcome.

OBJECTIVES: To assess the treatment adequacy for Staphylococcus aureus bacteraemia (SAB) and its association with outcome on a whole population basis. METHODS: All individuals ≥18 years old diagnosed with SAB in Iceland between December 1 2003 and November 30 2008 were retrospectively identified. Clinical data was collected from medical records and adequacy of antibiotic treatment based on antibiotic choice, dose, administration route and treatment duration. RESULTS: Empirical therapy was considered adequate in 262 of 325 (81%) SAB episodes, with no correlation to outcome. The complete antibiotic treatment was deemed adequate in 147 of 279 (53%) episodes. Among patients with complicated SAB median duration of active intravenous therapy was 14 days in those experiencing relapse compared to 30 days in patients without relapse (p = 0.03). No patient died after completing adequate treatment compared to 4 (3.0%) following inadequate therapy (p = 0.01). Despite no overall change being seen in antibiotic treatment, 30-day mortality decreased from 25.0 to 6.8% from first to last year of study (p = 0.001). CONCLUSION: Appropriate antibiotic therapy for SAB was associated with lower relapse rates and mortality. Although treatment adequacy was regarded as insufficient in half of cases, mortality of SAB in Iceland is amongst the lowest recorded. SUMMARY: In a national study of S. aureus bacteraemia the antibiotic treatment was judged inadequate in 53% of episodes, while appropriate treatment was associated with lower relapse rate and mortality. Despite this, the mortality in Iceland is among the lowest reported.

Changing epidemiology of methicillin-resistant Staphylococcus aureus in Iceland from 2000 to 2008: a challenge to current guidelines.

The epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) is continuously changing. Iceland has a low incidence of MRSA. A "search and destroy" policy (screening patients with defined risk factors and attempting eradication in carriers) has been implemented since 1991. Clinical and microbiological data of all MRSA patients from the years 2000 to 2008 were collected prospectively. Isolates were characterized by pulsed-field gel electrophoresis (PFGE), sequencing of the repeat region of the Staphylococcus protein A gene (spa typing), staphylococcal cassette chromosome mec (SCCmec) typing, and screening for the Panton-Valentine leukocidin (PVL) gene. Two hundred twenty-six infected (60%) or colonized (40%) individuals were detected (annual incidence 2.5 to 16/100,000). From 2000 to 2003, two health care-associated outbreaks dominated (spa types t037 and t2802), which were successfully controlled with extensive infection control measures. After 2004, an increasing number of community-associated (CA) cases without relation to the health care system occurred. A great variety of clones (40 PFGE types and 49 spa types) were found, reflecting an influx of MRSA from abroad. The USA300 and Southwest Pacific (SWP) clones were common. SCCmec type IV was most common (72%), and 38% of the isolates were PVL positive. The incidence of MRSA in Iceland has increased since 1999 but remains low and has been stable in the last years. The search and destroy policy was effective to control MRSA in the health care setting. However, MRSA in Iceland is now shifting into the community, challenging the current Icelandic guidelines, which are tailored to the health care system.

[Intensive care patients with influenza A (H1N1) infection in Iceland 2009]. / Gjörgaeslusjúklingar med inflúensu A (H1N1) á Islandi 2009.

BACKGROUND: We describe the main characteristics of patients that required intensive care due to the influenza (H1N1) outbreak in 2009. METHODS: Retrospective and prospective analysis of medical records from patients admitted to ICU with positive RT-PCR for (H1N1). RESULTS: During a six week period in the fall of 2009, 16 patients were admitted to intensive care in Iceland with confirmed H1N1 infection. Mean age was 48 years (range 1-81). Most patients were considered quite healthy but the majority had risk factors such as smoking, obesity or hypertension. All but one had fever, cough, dyspnea and bilateral infiltrates on chest x-ray and developed any organ failures (mean SOFA score 7). 12 needed mechanical ventilation and two extra corporeal membrane oxygenation (ECMO). Mean APACHE II score was 20. No patient died in the ICU but one elderly patient with multiple underlying diseases died a few days after being discharged from the ICU. CONCLUSIONS: (1) The incidence of severe influenza A (H1N1) that leads to ICU admission appears to be high in Iceland. (2) Many patients developed acute respiratory distress syndrome in addition to other organ failures, and required additional measures for oxygenation such as prone position, nitric oxide inhalation and ECMO. (3) 28 day mortality was low. (4) This study will aid in future outbreak planning in Iceland. Key words: influenza A, pneumonia, multiple organ failure, death rate, intensive care, ventilator therapy, ECMO.