[Organ donation following physician-hastened death at home]. / Orgaandonatie na euthanasie vanuit de thuissituatie.

Patients considering physician-hastened death (PHD) increasingly express a wish to donate organs after death. This fairly unique proposition stems from patients' desire to do something good with (parts of) the same diseased body that has prompted them to request physician-hastened death. In this article we describe a patient with amyotrophic lateral sclerosis (ALS) who expressed this wish. In March 2017 a national guideline on 'Organ donation following physician-hastened death' (ODP) was presented to the Minister of Health, Welfare and Sport of the Netherlands. From the development of this guideline it emerged that, for PHD patients, being forced to experience their final conscious moments in hospital - in order to facilitate organ donation - was a key reason for not choosing ODP. Together with an anaesthesiologist-intensivist, the GP of the ALS patient developed a domestic ODP, thereby overcoming the hurdle of experiencing death in hospital and maintaining the possible option of organ donation. The applied solution is an 'anaesthesia bridge' which separates the experience of farewells, and losing consciousness under pre-medication at home, from biological death and organ donation in hospital.

Slime-producing properties of coagulase-negative staphylococci isolated from blood cultures.

OBJECTIVE: To evaluate five methods for the determination of slime-producing properties in coagulase-negative staphylococci (CNS). METHODS: One hundred and sixty-two strains of CNS considered as 'contaminants' and 162 strains associated with 'bacteremia' were tested with the tube test with tryptic soy broth, the tube test with brain---heart infusion broth supplemented with 5% sucrose, the Congo red agar method, and the microtiter-plate test with trypan blue and crystal violet, both with tryptic soy broth. RESULTS: Of the 324 strains tested, 188 were negative and 58 were positive with all methods. The remaining 78 strains were positive with one or more methods. CONCLUSIONS: There was a significant difference (p<0.001) in slime production between 162 strains of CNS pertaining to 'bacteremia' and 162 strains considered as 'contaminants', with 84 (51.8%) and 52 (32.8%) positive, respectively. The slime-producing strains were significantly more resistant (p<0.001) to cloxacillin, tobramycin, gentamicin, trimethoprim, erythromycin and ciprofloxacin.

The relationship between the use of flucloxacillin, vancomycin, aminoglycosides and ciprofloxacin and the susceptibility patterns of coagulase-negative staphylococci recovered from blood cultures.

Antibiotic use is a cause of selection of multiresistant bacterial strains. Over three years (1990-1992) we studied the relation between the use of flucloxacillin, vancomycin, aminoglycosides and ciprofloxacin and the susceptibility of coagulase-negative staphylococci (CNS) recovered from blood cultures. Although there was no increase in the use of flucloxacillin, the susceptibility of CNS to this antibiotic decreased from 25% to 6%. No increase in aminoglycoside use was seen, though the use in the non-surgical intensive care unit was 40 times the average use in the hospital. The susceptibility to gentamicin declined from 36% to 15% for the rest of the hospital and to zero for the non-surgical intensive care unit. Vancomycin use did not change in the hospital as a whole, but the use in the haematological unit was about ten times that in the rest of the hospital. No single resistant strain (vancomycin MIC > or = 4 mg/L) was found. A three-fold increase in ciprofloxacin use was seen. After a decline in the susceptibility to ciprofloxacin from 72% to 58% in 1991, there was a small recovery to 62% in 1992. The use in the haematological unit was about 20 times that in the rest of the hospital. Ciprofloxacin susceptibility declined from 40% to 25% in that unit in 1991. In 1992 there was a small recovery to 29%.

Comparison of disk diffusion, the E test, and detection of mecA for determination of methicillin resistance in coagulase-negative staphylococci.

The aim of this study was to find a reliable, fast, and simple alternative to the methicillin disk method for determination of methicillin resistance in coagulase-negative staphylococci, since results of this method are often difficult to read due to growth within the zone of inhibition. The sensitivity of 319 strains of coagulase-negative staphylococci to a 5 microgram methicillin disk on Mueller-Hinton agar using an incubation period of 48 h was compared with that of 1 microgram and 5 micrograms oxacillin disks on Mueller-Hinton agar with or without 2% NaCl, using an incubation period of 24 h. The detection of mecA (MecAgen) by the polymerase chain reaction was used as a standard. Minimum inhibitory concentrations were determined by means of the E test. Of the 225 mecA-positive strains, 190, 215, and 193 were resistant to 5 micrograms methicillin, 1 microgram oxacillin and 5 micrograms oxacillin disks on Mueller-Hinton agar, respectively, and 216, 218, and 223 were resistant on Mueller-Hinton agar with 2% NaCl. Of the 94 mecA-negative strains, 89, 93, and 94 were susceptible to 5 micrograms methicillin, 1 microgram oxacillin, and 5 micrograms oxacillin disks on Mueller-Hinton agar, respectively, and 92, 93, and 94 were susceptible on Mueller-Hinton agar with 2% NaCl. Using breakpoints of 2 micrograms/ml for oxacillin resistance and 8 micrograms/ml for methicillin resistance, the E test yielded sensitivities of 99.6 and 99.1% and specificities of 97.9 and 98.9% after 48 h of incubation. The 5 microgram oxacillin disk was faster and easier to read than the methicillin disk and correlated better with detection of mecA than the methicillin disk of the 1 microgram oxacillin disk.

A simple and inexpensive method for the identification of Staphylococcus epidermidis and Staphylococcus hominis.

Eight hundred and ninety-two strains of Staphylococcus species were identified by means of desferrioxamine susceptibility and fermentation results of three carbohydrates, with the API Staph system (bioMérieux, France) as reference method. No identification could be obtained for 34 strains with API Staph. Of the remaining 858 strains, identical identification was obtained with 842 (98.1%). All 707 strains identified as Staphylococcus epidermidis or Staphylococcus hominis by the API Staph system were found to be desferrioxamine susceptible, and all but 5 (3.3%) of 151 strains identified as other staphylococcal species were found to be resistant, yielding an identification correlation of 99.4% for desferrioxamine. The five additional strains which were susceptible to desferrioxamine were identified as Staphylococcus capitis (2 strains), Staphylococcus lugdunensis (2 strains), and Staphylococcus warneri (1 strain) by API Staph, and as Staphylococcus epidermidis (1 strain), Staphylococcus hominis (3 strains), and one other staphylococcal species by the experimental system.

Comparison of Amplicor, in-house PCR, and conventional culture for detection of Mycobacterium tuberculosis in clinical samples.

Five hundred four clinical specimens (337 sputum and 167 bronchial samples) from 340 patients were tested for the presence of M. tuberculosis complex by the Amplicor M. tuberculosis test and by an in-house PCR. The results were compared with those obtained by conventional culture and by direct microscopy. Thirty specimens (from 14 patients) were positive by in-house PCR, 25 (from 13 patients) were positive by the Amplicor M. tuberculosis test, and 24 (from 10 patients) were positive by culture. Cultures from 16 specimens were contaminated with other bacteria. Strong inhibition of in-house PCR was found with three samples. After discordancy analyses, with clinical data as supportive evidence for tuberculosis, 27 true-positive and 458 true-negative samples were defined. On the basis of these figures, the sensitivities of the Amplicor M. tuberculosis test, in-house PCR, culture, and microscopy were 70.4, 92.6, 88.9, and 52.4%, respectively. The specificities of all four tests were higher than 98%. The good performance of the in-house PCR for detection of M. tuberculosis makes it a very useful additional tool in M. tuberculosis diagnostics. In contrast, the Amplicor test needs to be improved. Twenty-three of the Amplicor-negative samples were further tested for inhibition of the Amplicor system by retesting the DNA extracts after the addition of M. tuberculosis DNA. In 15 of these samples, 5 true positives and 10 true negatives, inhibition of the Amplicor test was demonstrated. This might explain the lack of sensitivity of the Amplicor test. If the inhibition problem can be solved, the Amplicor M. tuberculosis test, which is already rapid, very user-friendly, and reasonably priced, may certainly become very useful in microbiological laboratories.

Lactobacillus septicemia, an unusual complication during the treatment of metastatic choriocarcinoma.

A case of severe Lactobacillus septicemia in a patient treated with chemotherapy because of metastatic choriocarcinoma is described. Although Lactobacillus is a ubiquitous commensal of the female genital tract, no earlier reference was found in the literature.

Low dose oral tobramycin treatment for selective decontamination of the digestive tract: a study in human volunteers.

Tobramycin has been given orally to eight human volunteers for four successive days, to investigate its effect on the Gram-negative enterobacilli as well as on the endogenous anaerobic microflora. The effect was investigated in three treatment legs; i.e. in daily doses of 300 mg, in daily doses of 500 mg and thirdly in daily doses of 200 mg in combination with 1000 mg of neomycin. With 300 mg tobramycin daily, seven of eight volunteers had no Gram-negative bacilli in their faecal cultures by about four days after the onset of treatment. Their anaerobic micro-flora was slightly affected during treatment as evidenced by the appearance of low concentrations of beta-aspartylglycine in their stools. The other dose regimens were not significantly more effective in eliminating Gram-negative bacilli from the intestines; the anaerobic flora however, was more severely affected. Because evidence of induction of resistance was noticed it is recommended that if tobramycin is used for selective decontamination of the intestinal tract it should be given in combination with another antimicrobial drug such as polymyxin.