Ground water as the source of an outbreak of Salmonella Enteritidis.

In September 2014, an outbreak of gastroenteritis was reported to the Public Health Institute of Sibenik and Knin County in Croatia. The outbreak occurred in the County center of Sibenik, a town with 50,000 inhabitants, and it lasted for 12days. An epidemiological investigation suggested a nearby water spring as the source of the outbreak. Due to the temporary closure of the public water supply system, the inhabitants started to use untreated water from a nearby spring. Microbiological analysis revealed that the outbreak was caused by Salmonella enterica subsp. enterica serovar Enteritidis that was isolated from stool samples of the patients and ground water. The isolates were further analysed with pulsed-field gel electrophoresis using XbaI, which revealed an identical macrorestriction profile. Although 68 cases were reported, it was estimated that the actual number of affected persons was more than several hundred. In order to prevent further spread of disease, public advice was released immediately after the first epidemiological indication and a warning sign was placed at the incriminated water source, after microbiological confirmation. It is necessary to regularly monitor microbiological quality of ground water especially in urban areas and provide adequate education and awareness to the inhabitants regarding the risk of using untreated ground water.

[Infections during the first posttransplant year--experience at Sibenik General Hospital]. / Infektivne komplikacije u primatelja bubrega tijekom prve godine nakon transplantacije: iskustvo zupanijske bolnice Sibenik.

AIM: The aim of this study was to assess the frequency and type of infective complications in kidney recipients during the first year after transplantation. PATIENTS AND METHODS: We retrospectively analyzed data on the diagnosis and treatment of infective complications in 36 patients transplanted from 2004 until September 2012 (22 men and 14 women), age at the time of transplantation 19-73 years. We recorded the incidence of urinary tract infections, clinical variants (asymptomatic bacteriuria, acute pyelonephritis, sepsis) and etiology, i.e. causes, pneumonia, viral infections and cytomegalovirus infections (CMV) (with special reference to the use or no use of prophylactic valganciclovir), polyoma virus infection, BKV, JC, Epstein-Barr virus, and herpes zoster virus. RESULTS: The most common infective complication, uroinfection, was recorded in 69% of patients, of which 68% had one or more relapses. The most common clinical form of the infection was acute tubulointerstitial nephritis, caused by Klebsiella pneumoniae (of which 4 cases of ESBL Klebsiella pneumoniae). Pneumonia occurred in 4 transplant patients, one CMV pneumonia, other of bacterial origin. CMV infection and BKV occurred in 17% and herpes zoster infection in 11% of patients. One patient was diagnosed with EBV meningoencephalitis. One-year graft survival was 100% in patients without urinary tract infections in the first year after transplantation (31% of all patients) and 96% in patients with infections (69% of all patients).Three-year graft survival rate was 100% in patients without infection and 96% in patients with infections in the first year after transplantation. One- and three-year graft survival in patients with chronic hepatitis C was 100%. It was a small group of patients (5/36, 14%); the incidence of urinary tract infections amounted to 60%, and of CMV and BK virus to 20%. CONCLUSION: Infections are a common problem after kidney transplantation, which can be treated in a secondary care hospital.

Phacoemulsification in eyes with white cataract.

Phacoemulsification of white cataracts is associated with some difficulties and a higher rate of intraoperative complications. The aim of this report is to describe one of these cases and the possible ways to manage them. We report on cataract surgery in a 79-year-old patient with white mature cataract and insufficient mydriasis because of the pseudoexfoliation syndrome. The use of vital dyes for staining the anterior capsule enhances visualization and helps perform continuous curvilinear capsulorrhexis, which is a key point for performing successful phacoemulsification. In case of small pupils because of insufficient pharmacological mydriasis, we can either enlarge the pupil or work through it. Meticulous preoperative biomicroscopic and A-scan examination (the type of cataract according to intralental A-scan findings) can help select appropriate phaco technique. Despite a higher rate ofintraoperative complications, white cataracts can be safely operated on with phacoemulsification technique.

[ISKRA guidelines on antimicrobial treatment and prophylaxis of urinary tract infections--Croatian national guidelines]. / ISKRA smjernice antimikrobnog lijecenja i profilakse infekcija mokracnog sustava--hrvatske nacionalne smjernice.

These guidelines refer to diagnosis, antimicrobial treatment and prophylaxis of urinary tract infections in adults and children older than 12 years of age and cover lower urinary tract in females, uncomplicated pyelonephritis, complicated UTI with or without pyelonephritis, asymptomatic bacteriuria and recurrent UTI. These guidelines do not cover sexually transmitted diseases. The guidelines are primarily intended for use by general practitioners and specialists working in primary health care and hospitals. The members of the Working Group for the development of guidelines on antimicrobial treatment and prophylaxis of urinary tract infections were appointed by the Croatian Ministry of Health and Social Welfare. The project was financially supported by the Dutch government and professional assistance was provided by international consultants. The evidence for this guidelines is based on a systematic review of the literature, local antibiotic resistance data, the existing clinical protocols on the treatment and prophylaxis of UTIs, as well as suggestions and comments made by colleagues physicians during more than 50 continuous medical education courses held in the last three years on antimicrobial treatment and prophylaxis of UTIs. Draft version of the guidelines was available for comments on the web site http://iskra.bfm.hr and during the two-month piloting period the guidelines were widely presented to general practitioners, specialists working in primary care and hospitals--urologists, gynecologists, infectious disease specialists, nephrologists. The final version of the guidelines was approved by the Intersectoral Coordination Mechanism for the Control of Antimicrobial Resistance (ISKRA) Board.

[Mechanisms of resistance in Enterobacteriaceae towards beta-lactamase antibiotics]. / Mehanizmi rezistencije enterobakterija prema beta-laktamskim antibioticima.

Except for Salmonella spp., all Enterobacteriaceae produce intrinsic chromosomal encoded beta-lactamases which, beside their physiologic role in cell-wall synthesis and natural beta-lactam protection, are responsible for intrinsic resistance of individual species among Enterobacteriaceae. E. coli and Shigella spp. produce a small amount of AmpC beta-lactamases and are susceptible to ampicillin and other beta-lactam antibiotic agents. Enterobacter spp, C. freundii, Serratia spp., M. morganii, P. stuarti and P. rettgeri produce small amounts of inducible AmpC beta-lactamases which are not inhibited by beta-lactamases inhibitor, causing intrinsic resistance to ampicillin, co-amoxiclav and first-generation cephalosporins. K. pneumoniae produces small amounts of SHV-1 beta-lactamases, and K. oxytoca chromosomal K1 beta-lactamase, causing resistance to ampicillin, carbencillin, ticarcillin and attenuated zone of inhibition to piperacillin, compared to piperacillin with tazobactam. They are susceptible to beta-lactamase inhibitors. Whereas P. mirabilis shows a minor chromosomal expression of beta-lactamases, P. vulgaris produces chromosomal beta-lactamases of class A (cefuroximases), causing resistance to ampicillin, ticarcillin, and first- and second-generation cephalosporins. Antibiotics have caused the appearance of acquired or secondary beta-lactamases, with the sole function of protecting bacteria from antibiotics. The production of broad-spectrum beta-lactamases (TEM-1, TEM-2, SHV-1, OXA-1) results in resistance to ampicillin, ticarcillin, first-generation cephalosporins and piperacillin. A high level of beta-lactamases leads to resistance to their inhibitors. The plasmid-mediated extended-spectrum beta-lactamases (ESBLs) are of increasing concern. Most are mutants of classic TEM- and SHV-beta-lactamases types. Unlike these parent enzymes, ESBLs hydrolyze oxymino-cephalosporins such as cefuroxime, cefotaxime, ceftriaxone, ceftizoxime, ceftazidime, cefpirome and cefepime, aztreonam, as well as penicillins and other cephalosporins, except for cephamycin (cefoxitin and cefotetan). They are inhibited by beta-lactamase inhibitors. AmpC beta-lactamases are chromosomal and inducible in most Enterobacter spp., C. freundii, Serratia spp., M. morganii and Providentia spp. They are resistant to almost all penicillins and cephalosporins, to beta-lactamase inhibitors and aztreonam, and are susceptible to cefepime and carbapenems as well. Plasmid-mediated AmpC beta-lactamases have arisen through the transfer of chromosomal genes for the inducible AmpC beta-lactamase onto plasmids. All plasmid-mediated AmpC beta-lactamases have similar substrate profiles to the parental enzymes from which they appear to be derived. With one exception, plasmid-mediated AmpCs differ from chromosomal AmpCs in being uninducible. The National Committee for Clinical Laboratory Standards (NCCLS) has issued recommendations for ESBL screening and confirmation for isolates of E. coli, K. pneumoniae and K. oxytoca. No NCCLS recommendations exist for ESBLs detection and reporting for other organisms or for detecting plasmid-mediated AmpC beta-lactamases. High-level expression of AmpC may prevent recognition of an ESBL in species that produce a chromosomally encoded inducible AmpC beta-lactamase. AmpC-inducible species (e. g. Enterobacter spp. and C. freundii) can be recognized by cefoxitin/cefotaxime disk antagonism tests. Since clinical laboratories are first to encounter bacteria with new forms of antibiotic resistance, they need appropriate tools to recognize these bacteria, including trained staff with sufficient time and equipment to follow up important observations. Because bacterial pathogenes are constantly changing, training must be an ongoing process.